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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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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What should be taken into account from the 2019 recommendations of the European Atherosclerosis Society and European Society of Cardio-logy concerning dyslipidemia management for preventing atherosclerotic cardiovascular disease?

Olivier S. Descamps, Johan De Sutter, Ann Mertens, Caroline Wallemacq, Michel Langlois, Ann Verhaegen, Ernst Rietzschel, Guy De Backer Published in the journal : September 2020 Category : Internal Medicine

Several members of the Belgian Societies of Atherosclerosis and Cardiology have revisited in the form of 10 questions the main points of the new recommendations of the European Atherosclerosis Society (EAS) and European Society of Cardiology (ESC) concerning dyslipidemia management for preventing atherosclerotic cardiovascular disease (AVD). These new guidelines are underpinned by a number of key concepts, including the certainty that LDL cholesterol is the major cause underlying the development of atherosclerosis, that reducing LDL cholesterol helps diminish cardiovascular risk, that this cardiovascular benefit is the same regardless of how this reduction is met (nutrition, statin, ezetimibe, or PCSK9 inhibitor), and that there is neither a lower limit to this effect nor any danger at all of extremely low LDL cholesterol levels. To effectively put this knowledge into practice, a step-by-step approach is recommended; thereby enabling us to weight the intensity of the preventive approach based on individuals’ overall MCVA risk and their baseline (untreated) LDL-C levels.

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A rare cause of hypercalcemia

Charlotte Lepere (1), Jean-Cyr Yombi (1), Eric Van den Neste (2), Philippe D’Abadie (3), Halil Yildiz (1) Published in the journal : October 2019 Category : Internal Medicine

Hypercalcemia is a condition that must not be mistaken, because it can be life-threatening. Its severe form must be rapidly treated. We present the case of 66-year-old man presenting with neurologic symptoms and cardiac alterations secondary to severe hypercalcemia. The diagnostic work-up revealed excessive production of calcitriol secondary to Richter’s syndrome. After treatment of hypercalcemia and chemotherapy, the neurological symptoms and electrocardiographic changes completely disappeared. The aim of this article is to discuss the main etiologies of hypercalcemia, its clinical manifestations, and the principles of its management.

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A rare cause of hypokalemia

Jean Henry (1), Eugénie Lagneaux (1), Michel Lambert (2), Jean-Christophe Marot (1), Jean-Charles Coche (3) Published in the journal : October 2019 Category : Internal Medicine

Introduction. Hypokalemia is often discovered accidentally during routine check-ups. In some cases, however, it may be accompanied by severe symptoms like rhabdomyolysis, potentially leading to life-threatening cardiac rhythm disturbances.

Clinical case. We report the case of a 60-year-old woman admitted to the emergency department with marked anorexia, general weakness, diarrhea, and abdominal pain, which had progressively worsened over the last few weeks. Initial blood analyses showed hypokalemia (1.44mmol/L) as well as rhabdomyolysis (CK 6561 U/L). The cause of her condition could not be identified based on etiological investigations, whereas thorough history taking revealed massive chronic ingestion of cola (10 liters a day).

Discussion. The consumption of high quantities of cola can lead to hypokalemia through the effects of caffeine, glucose, and fructose. Caffeine induces severe hypokalemia by two mechanisms: intracellular redistribution of potassium and increased renal excretion of potassium. Additionally, substances with high fructose content cause osmotic diarrhea with secondary hypokalemia. The high glucose concentration in cola also induces hyperinsulinism, which is associated with intracellular redistribution of potassium.

Conclusion. Chronic and massive consumption of cola can lead to hypokalemia through intracellular potassium shifts, along with osmotic diarrhea caused by high fructose concentrations. Primary care physicians should inquire about soda consumption among their patients when confronted with unexplained cases of refractory hypokalemia.

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Clarkson’s disease: a rare capillary leak syndrome

Lilas Al Zein1, Cécile Yelnik2, Juliette Woessner2, Angélique Lemaire-Olivier2, Marc Lambert2, Pierre-Yves Hatron2 Published in the journal : January 2019 Category : Internal Medicine

Idiopathic capillary leak syndrome or Clarkson’s disease is a rare and potentially life-threatening condition. This condition presents with recurrent crises, characterized by the abrupt onset of generalized edema with relative hypovolemia associated with paradoxical hypoalbuminemia and elevated hematocrit levels. This almost pathognomonic clinical and biological presentation should remind us of the diagnosis, after excluding secondary causes of capillary leaks, and lead to initiating prompt supportive treatment in a specialized department, in an effort to avoid critical care and associated complications. This article describes the clinical characteristics of the disease and current knowledge about its physiopathology, natural history, and long-term prognosis, while highlighting the efficacy of first-line prophylactic therapy using intravenous immunoglobulins (IVIg) for relapse prevention, designed to avoid progression into a more severe form with gloomy prognosis.

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Travels and pregnancy: summary of current recommendations

Hélène Reul(1), Bernard Vandercam(2), Pascale Grandjean(3), Julien De Greef(4) Published in the journal : June 2018 Category : Internal Medicine

Travels and pregnancy are not incompatible. This article sought to provide an overview of the current recommendations on this topic and intends to be a tool for all practitioners, namely general practitioners, gynecologists-obstetricians, as well as midwives. To this end, we have chosen to investigate the following three topics: vaccination, malaria, and Zika virus. Vaccinating a pregnant woman is often possible and at times even recommended. Several vaccines, however, must be avoided, as they are live vaccines. Malaria during pregnancy may be severe, and appropriate prophylactic treatment should therefore be prescribed. Zika virus infection is associated with high risks for pregnant women. Appropriate precautions designed for pregnant women, women who plan to have a child, and partners of pregnant women have been summarized in this article. These guidelines based on national and international recommendations likely evolve over time and should therefore be updated on a regular basis.

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Cytomegalovirus infection associated with portal vein thrombosis and thrombocytopenia: a case report

Gianfranco Di Prinzio (1), Phung Nguyen Ung (2), Anne-Sophie Valschaerts (2), Olivier Borgniet (2) Published in the journal : April 2018 Category : Internal Medicine

We here present the case of portal vein thrombosis in a patient exhibiting symptoms of cytomegalovirus infection, confirmed by serology and polymerase chain reaction (PCR) and complicated by thrombocytopenia. The literature reveals growing evidence that human CMV likely plays a role in thrombotic disorders. However, only 11 cases of CMV-induced visceral venous thrombosis have been described so far. On the other hand, thrombocytopenia is a well-known complication of CMV infection. The patient was successfully treated using high-dose immunoglobulins by intravenous route

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Rare and serious complications related to granulomatosis with polyangiitis

Published in the journal : April 2018 Category : Internal Medicine

Granulomatosis with polyangiitis is a rare systemic vasculitis with significant morbidity and mortality. The diagnosis is based on the association of clinical signs, such as involvement of upper and lower respiratory tract, as well as of the kidney, along with the presence of specific antibodies (ANCA anti-PR3), and confirmation of histopathological biopsy specimen. Although the current treatment of the disease has resulted in significantly reduced mortality, morbidity remains very high, which is linked to both the disease itself and the undesirable effects of immunosuppressive therapy.

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Management of fever in splenectomized adults: case report and theoretical reminder

Halil Yildiz, Lucie Wartique, Jean-Cyr Yombi Published in the journal : September 2017 Category : Internal Medicine

In asplenic patients, fever should never be trivialized. The clinical presentation of a severe infection can be unspecific (fever, chills, sore throat, diarrhea, vomiting, and muscle aches). If an antibiotherapy is not given rapidly, the evolution can be abrupt, and patients can develop a disseminated intravascular coagulation. We here describe the case of a 77-year-old splenectomized female patient. Given the unspecific clinical presentation, the diagnosis of acute gastro-enteritis was made; however, the patient developed a severe pneumococcal infection. With this case report, we would like to remind the adequate management of fever in asplenic patients in order to avoid severe, potentially life-threatening, complications

Key Words

Fever, splenectomy, antibiotherapy, vaccination, education

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