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INTRODUCTION: Newer modalities like immunotherapy with checkpoint inhibitors are widely being used in oncology. Complete remission with immunotherapy comes along with immune related adverse effects which warrant prompt diagnosis and treatment. Below is a case metastatic RCC treated with pembrolizumab, humanized monoclonal antibody to programmed cell death receptor with autoimmune complications during therapy and subsequent complete remission after re-challenge. MATERIALS: 72 year old gentleman with background history of diabetes mellitus, hypertension presented with complaints of hematuria and neck pain. Upon evaluation, found to have RCC with metastasis to lungs and left occipital condyle. Patient underwent excision nd prosthesis for unstable atlanto-occipital joint, left nephrectomy for malignant focus in left kidney. He was then started on immunotherapy, inj. pembrolizumab +tab. axitinib. RESULT: After three cycles of immunotherapy, patient presented with easy fatigability, weakness and drowsiness. Baseline TSH and liver functions were normal. Investigations revealed high TSH and transaminitis. Autoimmune hepatitis was treated with steroids and oral levothyroxine was started for autoimmune thyroiditis. Patient improved with treatment and immunotherapy was re-challenged. After 12 cycles of pembrolizumab, review PET-CT scan showed no lung lesions and complete metabolic response. CONCLUSION: Immunotherapy has very good results in advance malignancies. It has unique side effects of auto immune phenomenon. Therapy can be re-challenged if its complications of autoimmune adverse events are diagnosed and treated promptly. References Nagra NK, Siddique A, Singhvi G, et al. S2684 pembrolizumab induced hepatitis: a severe complication effectively treated with steroids. Am J Gastroenterol 2020;115:S1405-S1406. Choueiri TK, Tomczak P, Park SH, et al. Adjuvant pembrolizumab after nephrectomy in renal-cell carcinoma. N Engl J Med 2021;385:683-694.
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Antineoplásicos Inmunológicos , Carcinoma de Células Renales , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos , Neoplasias Renales , Anciano , Humanos , Masculino , Antineoplásicos Inmunológicos/efectos adversos , Carcinoma de Células Renales/terapia , Inmunoterapia/efectos adversos , Neoplasias Renales/terapia , Tomografía Computarizada por Tomografía de Emisión de Positrones , Esteroides/uso terapéutico , TirotropinaRESUMEN
BACKGROUND: The endovascular approach of ablation of renal sympathetic nerves is found to be effective in the treatment of uncontrolled hypertension. We report here our experience with the procedure in eight patients with drug resistant hypertension. METHODS: We included patients in whom the blood pressure remained above 150/90 mmHg despite being on minimum three antihypertensive drugs. Radiofrequency ablation of the sympathetic nerves of both the renal arteries was done using conventional ablation catheters. The patients were followed at 1-month, 3 months and 6 months post procedure and blood pressure recorded. RESULTS: All patients underwent successful renal sympathetic denervation. The mean blood pressure of the patients was 181/102.5 mmHg before the procedure and the average requirement of antihypertensive drugs per day was 4. A significant reduction in both systolic and diastolic blood pressure was observed post procedure which sustained over the follow up period of six months. The mean blood pressure observed at 1-month, 3 and 6 months were 137.5/80 mmHg, 136/81 mmHg and 137.5/81 mmHg, respectively. The average requirement of the number of antihypertensives also was reduced to 2.5 at the end of 6 months. There were no procedural complications. CONCLUSION: Catheter based renal denervation causes substantial and sustained blood pressure reduction without serious adverse events in patients with resistant hypertension.
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Ablación por Catéter , Hipertensión/cirugía , Riñón/inervación , Simpatectomía/métodos , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
Anecdotal reports of acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome) with cytomegalovirus (CMV) suggested as the etiological agent have been described in transplant recipients with poor prognosis. We describe a 48-year-old man, a cadaveric renal allograft recipient on cyclosporine, mycophenolate mofetil and prednisolone, who developed febrile illness with unexplained anemia followed by progressive weakness of the upper and lower limbs. He was diagnosed as a case of Guillain-Barré syndrome (GBS). His CMV serology was positive by polymerase chain reaction (PCR). We treated him with both gancyclovir and intravenous immunoglobulins within a week of the onset of GBS and observed rapid recovery. Thus, search for CMV is warranted in transplant patients presenting with GBS, as early initiation of treatment with gancyclovir and immunoglobulins can help expedite recovery.