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Efficacy of 177Lu-Dotatate Therapy in the Treatment of Recurrent Meningioma
A 62-year-old man presented with a history of atypical meningioma (World Health Organization grade II) and recurrent as anaplastic meningioma (World Health Organization grade III). His previous treatments included multiple surgical resections, fractionated radiation therapy, stereotactic radiosurgery, everolimus/octreotide long-acting release, bevacizumab, and hydroxyurea. Magnetic resonance imaging revealed rapid volumetric progression over the prior 9 months, with a near tripling in size from 29.9 cm3 to 80.4 cm3.Pulmonary Vascular Disease Due to Plasma Cell Dyscrasia
Pulmonary hypertension (PH) has been described in myeloproliferative disorders; monoclonal plasma cell disorder such as polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome; and plasma cell dyscrasias such as multiple myeloma and amyloidosis. We describe 4 cases of PH likely due to pulmonary vascular involvement and myocardial deposition from light chain deposition disease, amyloidosis, and multiple myeloma. On the basis of our clinical experience and literature review, we propose screening for plasma cell dyscrasia in patients with heart failure with preserved ejection fraction, unexplained PH, and hematological abnormalities.Progressive Monoarticular Inflammatory Arthritis Following Influenza Vaccination
Musculoskeletal injury is an uncommon but usually self-limited complication of vaccine administration. We present a case of progressive inflammatory monoarthritis of the shoulder characterized by bone erosion, bursitis, and severe synovitis caused by an influenza vaccine administered to the ipsilateral deltoid region. Clinical symptoms began within 2 hours of vaccination, with progressive decline in function over 6 weeks. Magnetic resonance imaging examinations performed 5 months apart demonstrated progressive erosive changes of the greater tuberosity, rotator cuff injury, and extensive enhancing synovitis of the glenohumeral joint and subacromial/subdeltoid bursa.Acute Herpes Zoster Radiculopathy of the Lower Extremity With Dermatomal Rash and Lumbar Nerve Enhancement on MRI
Herpes zoster is a frequent cause of neuralgia and dermatomal vesicular rash secondary to reactivation of latent varicella zoster virus. However, it rarely presents with acute lumbar radiculopathy and the diagnosis can be quite challenging in such cases. Nerve signal abnormalities on magnetic resonance imaging are well recognized in herpes zoster neuropathy or plexopathy affecting the extremities, although gadolinium enhancement is characteristically absent. In this article, we describe a case of acute herpes zoster lumbosacral radiculopathy with characteristic vesicular dermatomal rash and second ever reported finding of gadolinium enhancement of the lumbar nerve on magnetic resonance imaging.Magnetic Resonance Imaging–Guided Focused Ultrasound Ablation of Lumbar Facet Joints of a Patient With a Magnetic Resonance Image Non-Conditional Pacemaker at 1.5T
To provide an initial report that patients with magnetic resonance imaging (MRI) non-conditional cardiac implanted electronic device (CIED) can undergo state-of-the-art magnetic resonance imaging–guided focused (MRgFUS) ablation procedures with careful planning and integration of the procedure into an established CIED MRI practice.Approaching Acute Vertigo With Diplopia: A Rare Skew Deviation in Vestibular Neuritis
Evaluating the patient with acute constant vertigo or diplopia can be a daunting task for clinicians, who recognize that such symptoms can be the manifestation of potentially devastating disorders like stroke but may be uncomfortable eliciting and interpreting the key symptoms and subtle signs that distinguish dangerous from benign causes. We present a novel and highly instructive case of a patient with acute vertigo and binocular diplopia from a large skew deviation due to vestibular neuritis. As the case unfolds, text and video commentary guide the clinician through the important elements of the history, bedside examination, and laboratory evaluation necessary for accurate diagnosis in the acute vestibular syndrome.Improved Treatment Response Following Magnetic Resonance Imaging–Guided Focused Ultrasound for Lumbar Facet Joint Pain
Magnetic resonance imaging–guided focused ultrasound (MRgFUS) is a noninvasive modality that allows for precise tissue ablation with sparing of surrounding structures. Early reports of the use of MRgFUS for the treatment of facet joint osteoarthritis are promising. We present a case of facet joint pain treated successfully by MRgFUS at our institution. Magnetic resonance imaging–guided focused ultrasonography may be a useful modality for patients with facet joint–mediated low back pain, particularly in the setting of limited or refractory response to conventional treatments.Dabrafenib and Trametinib Treatment for Erdheim-Chester Disease With Brain Stem Involvement
Erdheim-Chester disease (ECD) is a rare form of non–Langerhans cell histiocytosis characterized by infiltration of organs by CD68+ and CD1a− lipid-laden histiocytes, including the central nervous system in more than a third of patients. Molecular analysis of ECD samples has demonstrated the prevalence of BRAF V600E mutations as high as 54%. Recently, vemurafenib became the only Food and Drug Administration–approved treatment for patients with ECD who carry the BRAF V600E mutation. However, dabrafenib has been suggested to have greater brain distribution.Association of Immune-Mediated Cerebellitis With Immune Checkpoint Inhibitor Therapy
Immune-mediated encephalitis related to immune checkpoint inhibitor therapy is a rare but increasingly described condition that can cause significant morbidity. There are several reported cases in the literature but no previously described cases of immune-mediated cerebellitis. We describe a case of acute cerebellitis that developed in a 20-year-old man with primary refractory Hodgkin lymphoma being treated with the immune checkpoint inhibitor nivolumab. After exposure to 3 cycles of nivolumab, the patient had acute onset of headache, ataxia, nausea, and vomiting, with imaging findings of cerebellar edema, early tonsillar herniation, and early hydrocephalus.Brachial Plexus Neuritis Associated With Anti–Programmed Cell Death-1 Antibodies: Report of 2 Cases
Recently, guidelines have been outlined for management of immune-related adverse events occurring with immune checkpoint inhibitors in cancer, irrespective of affected organ systems. Increasingly, these complications have been recognized as including diverse neuromuscular presentations, such as demyelinating and axonal length–dependent peripheral neuropathies, vasculitic neuropathy, myasthenia gravis, and myopathy. We present 2 cases of brachial plexopathy developing on anti–programmed cell death-1 checkpoint inhibitor therapies (pembrolizumab, nivolumab).A Rare STRN-ALK Fusion in Lung Adenocarcinoma Identified Using Next-Generation Sequencing–Based Circulating Tumor DNA Profiling Exhibits Excellent Response to Crizotinib
The ALK gene fusion has been identified as a new driver gene in non–small cell lung cancer (NSCLC). It includes the EML4-ALK rearrangement as a recurring event that renders the tumor sensitive to ALK tyrosine kinase inhibitor crizotinib. In addition, several other fusion partners to ALK kinase domain (eg, TFG, KLC1, and KIF5B) have been identified in NSCLC. However, clinical data relevant to response in lung cancer harboring these rare ALK translocations are not fully available. A nonsmoking Chinese male originally diagnosed with “stage Ib lung adenocarcinoma” showed metastases in regional lymph nodes, pleura, and bone 1 year after surgery.
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