Multiple nonspecific symptoms in a patient treated by pembrolizumab

Victoria Van Hove, Sebahat Ocak, Etienne Delgrange Published in the journal : May 2021 Category : Internal Medicine

Immune checkpoint inhibitors, such as the receptor programmed cell death protein 1 (PD-1) or PD-1 ligand 1 (PD-L1), which are new therapeutic weapons against cancer, which are increasingly used nowadays.

This case report concerns a 72-year-old man treated by pembrolizumab (Keytruda®), a PD-1 inhibitor, in first-line systemic treatment of an Stage IVA lung adenocarcinoma. Three weeks before his eighth cure, the patient’s general condition deteriorated, including loss of appetite, fatigue, nausea, and a slight weigh loss. He also reported headaches. As an adrenal insufficiency was suspected, a substitution treatment consisting of hydrocortisone was initiated. The originality of this case lies in the relevance of also considering non-specific symptoms in cancer patients under immunotherapy, the emergency of the diagnosis, and the recommended medical management.

The aim of this article is direct your attention to this rare but potentially fatal adverse event of immunotherapy, with its new treatments that you will encounter increasingly often in your practice, and to revise some cases already published in the literature , in addition to another personal case.

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Ocular problems and bariatric surgery

Antoine Valembois, Gary Olders, Florence Aerts, Jean-Paul Thissen, Antonella Boschi Published in the journal : May 2021 Category : Ophtalmology

Objectives

- To report a case of severe hypovitaminosis A, responsible for bilateral blindness, which occurred 10 years after a bilio-pancreatic bypass.

- To recall the necessity of an early vitamin supplementation to obtain a remission of visual manifestations.

Method

Case report, review of the literature

Results

A 36-year-old man, who was followed-up and treated for keratoconus, was referred to our unit due to a progressive bilateral visual loss. The medical history revealed a gastric bypass surgery 10 years earlier, which had been followed by a biliopancreatic bypass.

Ophthalmological examination revealed bilateral blindness and severe dry eyes. The fundus was only visible at the right eye. On fundoscopy, the optic nerve was pale, and the retina showed diffuse pigmentary changes. There was a lack of response on the electroretinogram. Biological analysis revealed undetectable vitamin A levels, along with low levels of Cu, Zn, 25OHvitamin D, and vitamin E. The diagnosis of retinopathy and optic neuropathy due to nutritional deficiencies was made. Following treatment with vitamin supplementation, vision improved, yet in the right eye only.

Conclusions

Vitamin A deficiency associated with irreversible blindness is a clinical picture that is only rarely encountered in industrialized countries. Digestive malabsorption, especially if induced by bariatric surgery with biliopancreatic diversion, is a common cause. Recognition of the early symptoms, including xerophthalmia and night blindness, is essential to enable curative treatment to be initiated.

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Thrombosis and vaccines: a new challenge of the COVID-19 pandemic

Cédric Hermans, Michel Goldman Published in the journal : April 2021 Category : Hematology/Oncology

Venous thromboses at unusual locations, such as cerebral and visceral sites, along with thrombocytopenia have been detected in patients who received COVID-19 vaccines using adenovirus vectors. The concomitant presence of antibodies targeting platelet factor 4 is suggestive of an autoimmune process associated with heparin thrombocytopenia. These thromboses, although very rare, significantly impact the vaccination strategy.

This article seeks to review the available data on this topic. Accordingly, the observations that led to its identification, its hypothetical mechanisms, the diagnostic approach, as well as the therapeutic strategies to implement are presented in a concise and practical manner.

This article should help any health professional to better understand this rare vaccination-related complication and answer the patients' many questions.

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Advocacy for improvements in clinical nutrition training during the medical cursus

Jean-Paul Thissen, Anne Boucquiau, Nicolas Paquot, Jean-Charles Preiser Published in the journal : April 2021 Category : Endocrinologie et Nutrition

The knowledge of physicians in the field of nutrition mostly lags far behind the patients’ expectations, without complying with official recommendations. However, poor-quality nutrition and diet represent the first cause of mortality worldwide. As a result of insufficient training and poor awareness, many physicians do not meet patients’ expectations. Moreover, nutrition is often perceived as of low scientific value, thereby opening the area to numerous pseudo-scientific errancies. We advocate an overall improvement in nutrition training during the medical cursus, including transversal integration of nutritional insights into medical courses, in addition to the recognition of post-university training validated by academic authorities. A clarification of the roles and recognition of the competency framework are urgently required in order to further promote the professionalism of nutritional counselling.

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A systemic psychosocial medical approach to violence

Olivier Kabangu, Emmanuel de Becker Published in the journal : April 2021 Category : Psychiatrie infanto-juvénile

A difficulty for professionals in regular contact with psychic suffering often lies in the multiple repercussions of the situations encountered. Indeed, medico-psycho-social situations, which are usually worrying, exert a violent potential impact. Violence can be expressed in a noisy way or more insidiously, and on the societal level, as well. The systemic approach and its holistic declination provide relevant avenues of management. This contribution recalls the precise functions of this systemic approach, emphasizing the concepts of belonging and disengagement, while providing among other things a most original medium: the belonging program.

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Celiac axis compression (Dunbar) syndrome: literature revue on a common misdiagnosis of patients with chronic abdominal pain

Adam Abechri, Etienne Mauel Published in the journal : April 2021 Category : Chirurgie générale

Median arcuate ligament syndrome (MALS), which is also known as Dunbar syndrome, is a rare congenital condition. This syndrome is due to celiac trunk (CT) compression by the median arcuate ligament of the diaphragm, which causes diffuse abdominal pain owing to organic ischemia and nerve compression. This anatomical variant affects 10 to 24% of the general population, whereas only a small proportion develop clinical symptoms. Due to lack of knowledge, this anatomical abnormality can lead to prejudicial diagnostic wandering of patients with chronic abdominal pain. This article offers a review of the literature on MALS: the paper discusses its anatomy and clinical features, while also detailing various useful diagnostic explorations. The report compares certain treatments and highlights relevant predictive factors for its management.

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Management of asymptomatic bacteriuria: When to screen and when to treat?

Colin Hannesse, Halil Yildiz, Jean Cyr Yombi Published in the journal : April 2021 Category : Internal Medicine

Asymptomatic bacteriuria is defined as the presence of bacteria in the urine without any symptoms. It is very common, especially in the elderly. Despite clear national and international clinical guidelines, asymptomatic bacteriuria is far too often associated with screening and treatment. This strategy proves to be costly and promotes bacterial resistance, while exposing patients to the numerous undesirable effects of antibiotics. Unless specific urinary tract symptoms are present, a urine culture is only required for pregnant women, recent kidney transplant recipients (< 1 month), and prior to any urological procedures that likely cause mucous bleeding. For elderly patients with or without cognitive impairment who haven fallen or are confused, presenting with an otherwise asymptomatic bacteriuria, all infectious etiologies other than urinary causes must first be excluded before initiating any antibiotic therapy.

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D. Douillet, M. Hachez, A-C. Dekeister, M. Thoma, C. Grégoire, L. Levenbergh, R.Cre n, F. Dupriez, B. Rodrigues de Castro, .B. Germeau, C. Steinier, A.Penaloza Published in the journal : April 2021 Category : Emergency

Our Emergency department admits about 75000 patients on average per year, with many of them hospitalized. Emergency medicine is a true transversal specialty, enabling collaboration with colleagues from other departments. The wide range of pathologies, the acute disease phase, as well as the specificity of emergency treatments offers emergency physicians a clear opportunity to embark on research, innovation, and collaboration. The following five subjects illustrate these attractive features of emergency medicine.

• SARS-CoV-2 pandemic initiated a major increase in hospitalizations requirements, in addition to a change in patient flow management. The HOME-CoV rule has been developed to identify a subgroup of low-risk patients that can be treated securely as outpatients.

• The multidisciplinary care of severe trauma is a major challenge in emergency medicine. The potential lesions can indeed be of multiple origins. It is currently admitted that standardized protocols provide substantial benefit in patient care, with a significant impact on patient mortality. Implementation of such procedures in our emergency department has been instrumental for obtaining a supra-regional trauma center certification.

• Pain is a major reason for consultation in emergency departments. Indeed, pain is a true concern for individual patients, as much as for mass emergencies and disasters. Methoxyfluran (Penthrox®), which is an old and almost forgotten drug, has recently undergone new studies that have been published in literature.

• Clinical ultrasound (CUS) is carried out during the clinical examination, which substantially differs from the ultrasound performed in radiology departments. Evidence supports CUS use by emergency physicians at the patient’s bedside either to guide a procedure, help establish a differential diagnosis, select the complementary examinations of choice, or to guide treatments. All these procedures require the building up of a validated curriculum meeting international recommendations.

• Recent studies focused on pulmonary embolism (PE) have explored methods designed to reduce the number of computer tomography (CT) scans required. Given that among patients suspected of exhibiting PE, the prevalence of PE has significantly decreased, most CT examinations could thus be avoided. The 4-level pulmonary embolism clinical probability score (4PEPS) score integrates into a unique score a different method of clinical probability (CP) assessment, proposing a diagnostic strategy based on four levels of CP, resulting in a substantial reduction in imaging testing for patients with suspected PE.

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Atrial fibrillation and diabetes: role of direct oral anticoagulants

Cédric Hermans, Martin Buysschaert Published in the journal : March 2021 Category : Actualité thérapeutique

Non-valvular atrial fibrillation (NVAF) is the most common cardiac arrhythmia, and this condition constitutes a major indication for oral anticoagulant therapy. NVAF is particularly common in diabetic patients, who are at greater risk of developing thrombotic or bleeding complications. Direct oral anticoagulants (DOACs) are progressively replacing vitamin K antagonists (VKAs) among patients with NVAF. They are as effective as VKAs in reducing the risk of cerebral and systemic embolic events, while simultaneously decreasing severe and cerebral bleedings. Several recent studies have demonstrated DOACs to provide the same benefits in terms of efficacy and safety in diabetic versus non-diabetic subjects with NVAF. As suggested by the results of the ENGAGE AF-TIMI 48 study, among the DOACs, edoxaban given to diabetic NVAF patients appears to be associated with a significantly decreased risk of severe bleeding complications compared with VKAs.

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Ongoing therapeutic revolution in primary Type 1 hyperoxaluria

Arnaud Devresse, Nathalie Godefroid, Nada Kanaan Published in the journal : March 2021 Category : Nephrology

Primary hyperoxaluria Type I (PH1) is an autosomal recessive disease caused by the functional defect of hepatic alanine-glyoxylate aminotransferase, which results in overproduction of oxalate. The condition can be especially devastating for the kidneys, leading to end-stage renal disease (ESRD) during the first two to three decades of life in most patients. Currently, while the conservative treatment options are limited, they often prove inefficient in preventing ESRD. Consequently, many PH1 patients require kidney transplantation, and liver transplantation as well, which is currently the only definitive treatment option for counteracting the hepatic metabolic defect. Nevertheless, a therapeutic revolution is underway. Indeed, innovative drugs are currently being tested in clinical trials, and some preliminary data reveal their impressive efficacy in reduce hepatic oxalate overproduction. This paper reviews the current knowledge on this subject.

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