BMJ case reports
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Combined checkpoint inhibition therapy targeting the programmed cell death 1 (PD-L1) and cytotoxic T-lymphocyte associated protein 4 pathways has been a successful approach in the treatment of metastatic melanoma, leading to its investigation in the treatment of head and neck squamous cell carcinoma (HNSCC) with PD-L1 expression. Despite the potential for excellent responses, an increased rate of autoimmune neurological toxicity and paraneoplastic conditions has been observed when using these treatment modalities. ⋯ Although the patient experienced an impressive partial response with dual checkpoint inhibition, he suffered grade 4 neurotoxicity. Despite exciting advances in cancer immunotherapy, clinicians must be aware of the rare, debilitating and possibly previously undescribed paraneoplastic and autoimmune toxicities that may occur.
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Myocarditis is well known to be caused by viral infections such as Coxsackie virus group B, human herpes virus 6 and parvovirus B19. However, during the current emerging outbreak of SARS-CoV-2, there have been few case reports describing myocarditis as a possible presentation. In our case report we describe, early cardiac manifestations of SARS-CoV-2 in a UK District General Hospital. ⋯ Patient underwent treatment with milrinone and methylprednisolone that showed reduction in myocardial inflammation and significantly improved myocardial contractility. This was then followed by a second phase of SARS-CoV-2 associated pneumonia and renal failure requiring ventilatory support and haemofiltration. Although, not described in the literature, we have found conjunctive use of milrinone and methylprednisolone effective in patient with SARS-CoV-2 fulminant myocarditis.
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Case Reports
Survival case of acute and severe respiratory distress due to spontaneous tension gastrothorax.
A 20-year-old woman presented with abdominal pain and shortness of breath. She was in obstructive shock with absent breath sounds on the left haemithorax. ⋯ To confirm the diagnosis CT with contrast was done that revealed a huge left side diaphragmatic defect with abdominal contents in the thorax and mediastinal structures are shifted to left. She underwent emergency laparotomy and postoperative period was uneventful.
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Case Reports
Trimming the need for invasive ventilation: pragmatic critical care during the COVID-19 pandemic.
COVID-19 has challenged all medical professionals to optimise non-invasive positive pressure ventilation (NIV) as a means of limiting intubation. We present a case of a middle-aged man with a voluminous beard for religious reasons who developed progressive hypoxic respiratory failure secondary to COVID-19 infection which became refractory to NIV. After gaining permission to trim the patient's facial hair by engaging with the patient, his family and religious leaders, his mask fit objectively improved, his hypoxaemia markedly improved and an unnecessary intubation was avoided. Trimming of facial hair should be considered in all patients on NIV who might have any limitations with mask fit and seal that would hamper ventilation, including patients who have facial hair for religious reasons.