Louisiana Research Day Program Book 2025

Case Studies: Section 1

Case Studies: Section 1

Gonzalo Hidalgo, MD; Yameke Fletcher, OMS-III; Precious Omokaro, OMS-III Department of Neurology, Hardtner Medical Center, Urania, La 98 THE SILENT THREAT: A CASE OF OPTIC NERVE ATROPHY FROM UNDIAGNOSED NEUROSYPHILIS AND HIV

Mary Youssief, OMS-III 2 ; Nisheem Pokharel, MD 1 ; Ayesha Sadiq, MD 3 ; Swesha Shrestha, MD 3 ; Navin Ramlal, MD 3 1 St. Francis Medical Center, Monroe, LA; 2 VCOM-Louisiana; 3 St. Francis Medical Center, Monroe, LA 99 PEMBROLIZUMAB INDUCED TOXIC EPIDERMAL NECROLYSIS

Objective: The objective of this case report is to highlight a rare ocular manifestation of syphilis. A 31-year-old male presented to the neurology clinic with a 9-month history of progressive bilateral vision loss and associated headaches. His parents reported subjective memory loss and confusion. Previously, an ophthalmology clinic diagnosed optic nerve atrophy of unknown etiology. Symptoms began as unilateral vision loss in the left eye, later progressing to the right. The patient’s medical history was unremarkable except for an appendectomy. On physical examination, the patient appeared well and was in no acute distress. Extraocular movements were intact, and pupils were equal, round, and reactive to light; however, visual acuity testing was not documented. The patient was referred to the Emergency Department for further evaluation of suspected idiopathic intracranial hypertension or an alternative organic process affecting the optic pathway.Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast revealed no significant abnormalities. Laboratory investigations showed a complete blood count (CBC) and comprehensive metabolic panel (CMP) within normal limits. However,

C-reactive protein (CRP) was elevated at 11.0 milligrams per liter, indicating an inflammatory process. Human immunodeficiency virus (HIV) testing was positive, with a CD4 cell count of 290 cells per microliter and a viral load of 41,720 copies per milliliter. Lumbar puncture revealed positive Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR) tests with a titer of 1:16, elevated protein levels, and a white blood cell count of 114 cells per microliter, consistent with neurosyphilis. The patient was diagnosed with ocular and neurosyphilis in the context of HIV co-infection following infectious disease consultation. He was treated for neurosyphilis with intravenous penicillin for 14 days and initiated on Biktarvy (bictegravir, emtricitabine, and tenofovir) for HIV management. Neurosyphilis manifests through diverse presentations, underscoring the importance of meticulous history-taking and comprehensive physical examinations. Recognizing the varied signs is crucial for timely intervention, as proper treatment facilitates full patient recovery. Conversely, failure to identify the disease can result in adverse outcomes due to untreated conditions.

Introduction: Pembrolizumab (Keytruda) is a monoclonal antibody used in the treatment of several malignancies including but not limited to melanoma, triple-negative breast cancer, cervical cancer, esophageal cancer, and gastric cancer. It is a humanized monoclonal antibody that targets the checkpoint inhibitor known as programmed cell death receptor 1 (PD-1). Common adverse effects include fatigue, dyspnea, cough, musculoskeletal pain, and arthralgias. While pruritus and skin rashes are also common side effects, there are only a few cases documented of progression to Steven-Johnson Syndrome (SJS) and/or Toxic-Epidermal Necrolysis (TEN). Here, we present a case of TEN in a patient receiving Pembrolizumab. Case Summary: A 60-year-old female with a history of stage IIb (T2N1), ER/PR, HER2 negative (1+) right-sided breast cancer being treated with both chemotherapy and immunotherapy presented to the hospital with concerns of fever and worsening cough. Initial workup revealed right-sided pneumonia and she was subsequently admitted for sepsis. She was initially managed symptomatically along with intravenous cefepime and vancomycin

for pneumonia. During her hospitalization, the patient reported a worsening of generalized skin rash that had been present since the last chemotherapy cycle. Physical examination revealed a generalized peeling of the skin. She was receiving neoadjuvant chemotherapy with Paclitaxel/Carboplatin/Pembrolizumab and she had received her 4th dose of this regimen 15 days before presentation to the hospital. Her skin rash gradually worsened throughout her hospital stay and started desquamating, at which point a diagnosis of Toxic Epidermal Necrolysis was made due to the involvement of more than 50% body surface area. A review of current medications showed that Pembrolizumab was the most likely culprit. The patient was started on intravenous corticosteroids, and the rash markedly improved over the next 2discharged on a tapering dose of oral steroids for a total of 6 weeks of treatment. Upon her discharge, serial follow-ups at the outpatient clinic were scheduled with oncology to continue monitoring weeks. She was her for improvement. Pembrolizumab was subsequently discontinued and she has since been transitioned to a different chemotherapy regimen of Adriamycin and cyclophosphamide with no further complications.

Discussion: Pembrolizumab is used for immunotherapy of multiple malignancies and is currently undergoing clinical trials to treat several other cancers. Because its mechanism of action results in immunogenicity,al reports of immune-related side effects. Interestingly, there are several reports of a delayed onset of this drug reaction, there are sever with many patients requiring several weeks before improvement was noted. Treatment of SJS/TEN as a side effect of an immune checkpoint inhibitor such as Pembrolizumab has not been well-established, however, corticosteroids, IVIG and cyclosporine are used for treatment in some patients according to available literature. However, there are a few cases with immunosuppressive treatment that have been inadequate and have resulted in fatalities. Regardless, the development of SJS/TEN in a patient receiving Pembrolizumab therapy warrants immediate and permanent discontinuation of the drug. Although rare, oncologists must be aware of the potentially fatal side effects of SJS/TEN as a consequence of Pembrolizumab therapy for early recognition and prompt management.

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113 2025 Research Recognition Day