In recent years the use of immunomodulating therapy to treat various cancers has been on the rise. Three checkpoint inhibitors have been approved by the Food and Drug Administration (ipilimumab, pembrolizumab and nivolumab). The use of these drugs comes with serious adverse events related to excessive immune activation, collectively known as immune-related adverse events (irAEs). We conducted a system-based review of 139 case reports/case series that have described these adverse events between January 2016 and April 2018, found in the PubMed database. There was a broad spectrum of presentations, doses and checkpoint inhibitors used. The most common check point inhibitor observed in our literature review was nivolumab. The most common adverse effects encountered were colitis (14/139), hepatitis (11/139), adrenocorticotropic hormone insufficiency (12/139), hypothyroidism (7/139), type 1 diabetes (22/139), acute kidney injury (16/139) and myocarditis (10/139). The treatment most commonly consisted of cessation of the immune checkpoint inhibitor, initiation of steroids and supportive therapy. This approach provided a complete resolution in a majority of cases; however, there were many that developed long-term adverse events with deaths reported in a few cases. The endocrine system was the mostly commonly affected with the development of type 1 diabetes mellitus or diabetic ketoacidosis being the most frequently reported adverse events. While immunomodulating therapy is a significant advance in the management of various malignancies, it is capable of serious adverse effects. Because the majority of the cases developed pancreatic dysfunction within five cycles of therapy, in addition to the evaluation of other systems, pancreatic function should be closely monitored to minimize adverse impact on patients.

The utility of immunotherapy, such as pembrolizumab, is becoming essential in the treatment of certain cancers. Pembrolizumab works through binding of programmed cell death 1 receptor that blocks the binding of the programmed cell death ligand 1 and is commonly used in non-small cell lung cancer and melanoma. Pembrolizumab has been reported to be associated with multiple adverse reactions such as pneumonitis, colitis, hepatitis, hypophysitis, hyperthyroidism, hypothyroidism, nephritis, and type 1 diabetes; however, pembrolizumab causing type 1 diabetes was only reported in 0.1% of the patients in clinical trials. A review of the literature generated 1,001 unique citations of which six reported cases of autoimmune diabetes associated with pembrolizumab were selected and compared. Review of the cases showed no sexual predilection and the average age of onset was 58 years old. The majority of the patients were treated for melanoma (5/6 cases), initially presented with diabetic ketoacidosis (4/6 cases), and had at one point taken ipilimumab (4/6 cases). There was no association found between the number of treatments received and the development of diabetes. With the increasing use of pembrolizumab in cancer treatment regular blood glucose monitoring during treatment, especially in patients who had also taken ipilimumab, may prevent the onset of this life-threatening complication.

e15148 Background: Immune-related adverse events (irAEs) due to immune checkpoint inhibitors (ICIs) are caused by non-specific immune system activation and develop in 30-70% of patients. The goal of this study is to examine the association of race with the development of irAEs secondary to ICIs as autoimmune diseases generally exhibit racial differences. Methods: A retrospective chart review was done using University of Louisville pharmacy database. Patients with solid cancers who received ICIs between Jan 2016 to June 2019 were included. IrAEs were identified through the review of electronic medical records. Descriptive analysis evaluated the incidence and severity of irAEs. Multivariable logistic regression was used to calculate standardized incidence of irAEs among Whites and African Americans. Results: A total of 476 patients were included in this study. The mean age was 61 years, 57% were males and 89.7% were whites. A majority of patients had melanoma (50%). The remainder of the dataset included lung (33.4%), gastrointestinal (7.4%), head & neck (4.8%), breast (2.5%) and genitourinary (1.9%) cancers. ICIs included single agent anti-PD-1 (74.8%), single agent anti-PD-L1 (9.4%), combination anti-CTLA-4 with anti-PD-1 (7.1%). Some patients were also treated with > 1 ICI as subsequent therapy (8.6%). Overall, the rate of irAEs was 44.3% with 33.8% grade 1-2 and 12.4% grade 3-4 irAEs. There was no difference in development of any grade irAEs in Whites as compared to African Americans after adjusting for age, sex, cancer type and ICIs (44.3% vs 44.2%; OR: 0.99, 95% CI: 0.50 – 1.97; p = 0.99). There was also no difference in development of grade 3-4 irAEs in whites as compared to African Americans (12.8% vs 14.5%; OR: 1.16, 95% CI: 0.43 – 3.12; p = 0.75). Conclusions: In this study, we found no racial difference in the development of irAEs between Whites and African Americans. This is in contrast to general autoimmune diseases which exhibit racial differences with higher prevalence among African Americans compared to Whites. We will continue to accrue patients to this study as larger sample size is needed to confirm these findings.

Duplication of the inferior vena cava (DIVC) is an uncommon embryological anatomic phenomenon.We report a 63-year-old woman with extensive right leg deep vein thrombosis who required an IVC filter due to contraindications for anticoagulation, but was found to have DIVC which required the placement of two IVC filters with good result. This report will review and summarise past reports of DIVC management to provide a guide for future clinicians, and review the embryological development, diagnosis and IVC filter placement options as they are based on the type of anatomic malformation encountered.

The advances in our understanding of the alternative pathway have emphasized that uncontrolled hyperactivity of this pathway causes 2 distinct disorders that adversely impact the kidney. In the so-called atypical hemolytic uremic syndrome (aHUS), renal dysfunction occurs along with thrombocytopenia, anemia, and target organ injury to multiple organs, most commonly the kidney. On the other hand, in the so-termed C3 glomerulopathy, kidney involvement is not associated with thrombocytopenia, anemia, or other system involvement. In this report, we present 2 cases of alternative pathway dysfunction. The 60-year-old female patient had biopsy-proven C3 glomerulopathy, while the 32-year-old female patient was diagnosed with aHUS based on renal dysfunction, thrombocytopenia, anemia, and normal ADAMTS-13 level. The aHUS patient was successfully treated with the monoclonal antibody (eculizumab) for complement blockade. The patient with C3 glomerulopathy did not receive the monoclonal antibody. In this patient, management focused on blood pressure and proteinuria control with an angiotensin-converting enzyme inhibitor. This article focuses on the clinical differences, pathophysiology, and treatment of aHUS and C3 glomerulopathy.

Foreign body granulomatosis has many etiologies, including the injection of oral medications intravenously. The insoluble filler materials that are used in the medications can lodge in pulmonary arterioles and capillaries, which can trigger foreign body giant cell reaction, chronic inflammation, thrombosis, and fibrosis, resulting in pulmonary hypertension, progressive shortness of breath, and, potentially, fatal conditions. On imaging, this may present with multiple miliary mottling’s/nodules. The use of a bronchoscopy with biopsy can be an excellent way to establish a diagnosis in appropriate clinical settings. Here, we present a case of a 37-year-old old male found to have multiple miliary densities on imaging due to intravenous use of oral medication.

Introduction Histiocytic necrotizing lymphadenitis (HNL), also known as Kikuchi Fujimoto disease, is a disorder of unknown etiology. Diagnosis is made only with histological examination and is frequently misdiagnosed as lymphoma. Our objective is to maintain high index of suspicion to diagnose HNL and to emphasize on the role of hydroxychloroquine (HCQ) for management of complicated cases. Case 48 year old male with a past medical history of ankylosing spondylitis, uveitis, and hypothyroidism initially presented 4 years ago with fever, night sweats, vomiting and weight loss of 10 pounds over the past 1 month. The physical exam was significant for tender, mobile left supraclavicular lymphadenopathy with no hepatosplenomegaly. Laboratory findings revealed leukopenia, anemia and elevated liver enzymes, lactate dehydrogenase, erythrocyte sedimentation rate and C-reactive protein. He was given broad spectrum antibiotics with no improvement. Computed tomography of the chest/abdomen demonstrated mediastinal, hilar and abdominal lymphadenopathy. Further infectious and autoimmune workup was negative. The patient then underwent a left supraclavicular lymph node excision which was consistent with HNL (Figure 1). Flow cytometry of the lymph node revealed no diagnostic evidence of a lymphoproliferative disorder. He was started on prednisone and his symptoms resolved. He had multiple episodes of recurrence in the last 4 years, manifesting as high grade fever, fatigue and lymphadenopathy. He was treated each time with prednisone. No provoking factors including viral infection or flare of uveitis was evidenced. Most recently, he had 3 episodes within 12 month span. Eventually he was treated with HCQ and since, has had no recurrence. Discussion HNL is most commonly reported among young Asian females. The exact entity of this disease is unclear including its pathogenesis and treatment. No signs or symptoms are pathognomonic, making it a difficult diagnosis. Awareness of this disorder by clinicians would help prevent unnecessary treatment with antibiotics and allow earlier initiation of HCQ. Characteristic histopathologic findings of HNL include irregular paracortical areas of coagulative necrosis with karyorrhectic focus, distorting the nodal architecture. The foci are formed by predominantly histiocytes and plasmacytoid monocytes, also immunoblasts and lymphocytes. Neutrophils are absent and plasma cells are either absent or scarce. The histiocytes express antigens such as CD163 and CD68. Most cases of HNL have a self-limited clinical course, although 3-7% of patients experience recurrent episodes. Treatment is generally directed towards symptomatic relief. Use of short term administration of corticosteroids and nonsteroidal anti-inflammatory drugs may be effective. However preventing recurrence has been a challenge. Several reports have proposed a close association between HNL and autoimmune disorders. Therefore, it has been speculated that HCQ would be useful for treating HNL. Our patient had 3 recurrences within 4 years and with the use of HCQ, remission was finally achieved. Conclusion In past 1 year, two articles discussed the use of HCQ in HNL. Lin et al. presented a retrospective review of 40 children diagnosed with HNL over approximately 15 years. Corticosteroids and HCQ were administered in 15.6% of patients. There were neither recurrences nor relevant major adverse effects in cases treated with HCQ. Honda et al. reported a case of a 42 year old female with multiple recurrences following tapering dose of prednisone. Continuous remission was achieved by concomitant use of HCQ with prednisolone. Several other cases have been reported suggesting that HCQ is effective for treating HNL patients with Systemic lupus erythematosus (SLE). Despite our patient not meeting the American College of Rheumatology criteria of SLE, he still responded to HCQ and has been able to avoid unnecessary use of steroids. Further research is needed regarding management of HNL flares which do not present with obvious autoimmune symptoms. Lin, YC et al., Pediatric Kikuchi-Fujimoto disease: A clinicopathologic study and the therapeutic effects of hydroxychloroquine; https://doi.org/10.1016/j.jmii.2017.08.023 Honda et al; Recurrent Kikuchi-Fujimoto Disease Successfully Treated by the Concomitant Use of Hydroxychloroquine and Corticosteroids; Intern Med. 2017 Dec 15; 56(24): 3373-3377. Disclosures No relevant conflicts of interest to declare.

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