Sharolyn I Velazquez-Acevedo

Veterans Health Administration

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Janet Colon-Castellano

Health Affairs

Porfirio E Diaz-Rodriguez

VA Caribbean Healthcare System

Claudia M Muns-Aponte

Veterans Health Administration

Cristina M Ortiz-Malave

Veterans Health Administration

Jaymilitte Bosques-Lorenzo

VA Caribbean Healthcare System

Jose Acevedo

Veterans Health Administration

Francisco Merced-Ortiz

Veterans Health Administration

Joedali Baez-Torres

VA Caribbean Healthcare System

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VA Caribbean Healthcare System

Veterans Health Administration

Health Affairs

University of Puerto Rico System

Bruce W. Carter VA Medical Center

University Medical Center

Boston Medical Center

Boston University

Hospital General de México

Instituto Nacional de Cancerología

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An Uncommon Case of Myocarditis Secondary to Durvalumab Plus Tremelimumab

Cureus (2023)

Porfirio E Diaz-Rodriguez Claudia M Muns-Aponte Sharolyn I Velazquez-Acevedo Cristina M Ortiz-Malave Jose Acevedo

Tumor immunotherapy is an important clinical strategy for the treatment of various solid and hematological malignancies, and its use is on the rise. Immune checkpoint inhibitors (ICIs) are immunotherapies that boost anticancer immune responses by targeting receptors on the surface of T-lymphocytes. Two important ICIs are anti-programmed death ligand-1 (anti-PD-L1) monoclonal antibodies and anti-cytotoxic T-lymphocyte-associated antigen-4 (anti-CTLA-4) monoclonal antibodies. Tremelimumab (anti-CTLA-4) and durvalumab (anti-PD-L1) have been shown to be effective monotherapies. However, their combination has demonstrated effective and encouraging antitumor activity with manageable safety in patients with unresectable hepatocellular carcinoma. We present the case of an 80-year-old male with hepatocellular carcinoma who had undergone drug-eluting bead transarterial chemoembolization (DEB-TACE) on three occasions and had been started on a combination of ICIs, durvalumab, and tremelimumab. He subsequently developed various immune-related adverse effects in different organ systems, including hepatic and cardiovascular complications. Appropriate treatment was administered, but ultimately, he passed away. We aim to discuss the initial evaluation for suspected immune-related adverse events, specifically those related to myocarditis and its various manifestations, prognosis, and treatment.

Tremelimumab

Durvalumab

CTLA-4

10.7759/cureus.43628

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Citations (2)

FRI658 Diabetic Ketoacidosis Masked By Cannabis In Type 2 Diabetes Mellitus

Journal of the Endocrine Society (2023)

Jaymilitte Bosques-Lorenzo Sharolyn I Velazquez-Acevedo Joedali Baez-Torres Janet Colon-Castellano

Abstract Disclosure: J. Bosques-Lorenzo: None. S. Velazquez-Acevedo: None. J. Baez-Torres: None. J. Colon-Castellano: None. Background: With the legalization of cannabis in many states, cannabis-related emergency visits have doubled. In recent years, hyperglycemic ketosis and altered glycemic control have been more frequently described in diabetic patients who are also cannabis users. Physicians mostly rely on pH and bicarbonate to diagnose and classify diabetic ketoacidosis (DKA). However, diabetic-cannabis users with typical DKA symptoms may present with alkalosis rather than acidosis. Clinical Case: We present the case of a 71-year-old male patient with a history of insulin-dependent type 2 diabetes mellitus, hypertension, and hyperlipidemia who came to the ED with a chief complaint of increased tiredness, fatigue, polyuria, polydipsia, and a home blood glucose measurement of greater than 500 mg/dl. Labs were remarkable for central blood glucose of 528 mg/dl, b-hydroxybutyrate of 42.1 mg/dl, and anion gap of 18.5mEq/L. Urine was also positive for glucose and ketones. However, arterial blood gasses showed a pH of 7.438 and bicarbonate of 25.5 mmol/l which did not meet the criteria for typical DKA. Upon record review, the patient had prior toxicology tests which were positive for cannabinoids. This admission wasn’t the exception. Studies have suggested that diabetic cannabis users tend to present with metabolic alkalosis despite high anion gap ketosis. Therefore, the patient was managed as per DKA protocol with adequate response and improvement of symptoms. Conclusion: The diagnosis of DKA in cannabis users may be frequently missed due to its differing and conflicting acid-base profile compared with non-cannabis users. Gastric delay and frequent vomiting have been suggested as the likely cause of alkalosis in these patients. Our patient did not present with severe vomiting; therefore, this case suggests that an alternate mechanism for alkalosis is possible and that relying only on pH and bicarbonate can be misleading. This case highlights the importance of screening urine toxicology for cannabis in patients who do not meet the typical criteria for DKA (pH >7.4 and bicarbonate >15 mmol/L) to provide the most effective treatment. Presentation: Friday, June 16, 2023

Polyuria

Diabetic ketoacidosis

Polydipsia

Anion gap

Ketosis

Ketoacidosis

10.1210/jendso/bvad114.876

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Citations (1)