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A 60-year-old male presented to our institution for abdominal pain and was later admitted to the intensive care unit for shock, acute hypoxemic respiratory failure, and acute kidney injury. He was subsequently found to have a large left-sided pleural effusion with empyema secondary to Streptococcus constellatus. With the emerging threat and growing prevalence of Streptococcus anginosus group pathogens, there is now greater clinical importance in identifying viridans streptococci at the species level. While immunosuppressed individuals are at greater risk of opportunistic pathogens, this case presentation demonstrated that Streptococcus constellatus can remain a serious community-acquired pathogen for the non-immunosuppressed. Continued interprofessional team care management and a greater look into the reasons for greater Streptococcus anginosus pathogenicity may be indicated.

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Small cell lung cancer which constitutes about 15% of lung cancers is pathobiologically and clinically distinct from non small cell cancer. Histologically it is characterized by small cells with scant cytoplasm, absent or inconspicuous nucleoli, extensive necrosis, and expresses neuroendocrine markers. It is on a spectrum of neuroendocrine cancer that extend from typical carcinoids to large cell to small cell cancer. Clinically it behaves in a more malignant fashion with a rapid doubling time, early metastasis. They respond rapidly to cytotoxic treatment however tend to develop resistance soon. Immunotherapy with checkpoint inhibitors take advantage of PD 1 ligand-receptor axis between the tumor and T cells or CTLA4 on T cells which when engaged lead to inhibition of T cells. This inhibition helps tumors to evade immune surveillance. Checkpoint inhibitors break this axis by either binding to PD 1 ligands or PD 1 to CTLA4, thereby preventing tumors to evade the immune systems. This has led to remarkable responses in tumors. The immune related adverse effects can be severe however are experienced at much lower rates as compared to cytotoxic chemotherapy. Recently, CheckMate 032 has shown impressive response rates with Nivolumab and Nivolumab/Ipilimumab in relapsed small cell cancer. IMpower 133, a phase 3 trial showed that addition of Atezolizumab to Carbo/Etoposide led to a significant survival benefit in treatment naive extensive small cell cancer. This review will summarize recent developments and ongoing studies of immune therapy in extensive small cell cancer in addition to a brief summary of immune therapy landscape of Non small cell lung cancer. Investigational approaches to immune therapy have also been delineated.

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Tumor lysis syndrome is a constellation of metabolic disturbances commonly seen during therapy of bulky, rapidly proliferative tumors. Multiple myeloma is a low proliferation tumor with rare incidence of tumor lysis syndrome in the pre-Bortezomib era. Post Bortezomib use, a rise in the incidence of tumor lysis has been noted. We present seven cases of tumor lysis syndrome with three patients in spontaneous tumor lysis and four developing the same after chemotherapy. In the previous studies, elevated LDH and deletion of chromosome 13 has been associated with risk of TLS. In our study, we noted several abnormal karyotpes including del 9p13, del 17 and monosomy 13 were more frequently found but larger studies are needed to explore the causative nature of these associations. Prognosis in these patients is relatively poor reflecting the higher tumor burden. However, further studies are needed to learn about other poor prognostic markers.

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Osler-Weber-Rendu disease (OWRD) is a rare vascular dysplasia that presents most commonly with epistaxis. The most dreaded complication, however, is an intracranial haemorrhage. We present a patient with two rare manifestations of OWRD, subdural haematoma and portal venous hypertension, both seldom reported in the literature. The patient made a full recovery and continues to do well at this time.

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Sarcoidosis bone is uncommon, and involvement of the skull is exceptionally rare. We present a 65-year-old obese female who presented with a 2-month history of dryness of mouth, polyuria, fatigue, and anorexia. She had generalized lymphadenopathy, organomegaly, and hypercalcemia, and a skeletal survey revealed extensive osteolytic lesions in the skull and phalanges. Both lymph node biopsy from the cervical lymph node and bone marrow examination revealed non-caseating granulomas, suggesting sarcoidosis. She was started on 1 mg/kg oral corticosteroids; during a follow-up of 6 months, she achieved normocalcemia; however, the punched-out lesions in the skull remained unchanged. This case reiterates several important issues that all lymphadenopathy in emerging nations may not be tubercular, and presence of osteolytic lesions in skull are unusual for sarcoid, at an elderly age, necessitates evaluation for more common etiologies like metastases and myeloma. Finally, patients with osseous sarcoid should be on a close follow-up since due to the rarity of this presentation, no definite consensus on the management of such cases exists in the literature.

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