Background: Immune checkpoint inhibitor-induced (ICI) myasthenia gravis (MG) is rare but may present as a fulminant overlap syndrome with myositis and myocarditis. Case Presentation: A 63-year-old man with carcinoma of the oral cavity receiving Toripalimab presented with fluctuating ptosis, dysarthria, dysphagia, generalized weakness, and breathlessness. He developed type 2 respiratory failure requiring non-invasive ventilatory (NIV) support. Anti-AChR and anti-MuSK antibodies were negative, and RNST was non-decremental. Creatinine Kinase (CK), Serum Glutamic Pyruvic Transaminase (SGPT), and Serum Glutamic-Oxaloacetic Transaminase (SGOT) were elevated, supporting myositis. High-sensitivity troponin I, CPK-MB, and NT-proBNP were raised, supporting myocarditis overlap. Imaging excluded major alternate central and thromboembolic causes. He was treated with immunomodulatory therapies (intravenous methylprednisolone and immunoglobulin-IVIG). Conclusion: ICI-induced seronegative MG with myositis-myocarditis (MMM syndrome) overlap should be suspected in patients receiving PD-1 inhibitors who develop acute ocular-bulbar weakness and respiratory decline, even when antibody and electrophysiologic studies are negative. Early recognition is critical because... Continue Reading

Background: Sarcoidosis, as a rare disease, affects 0.01% of the population; involvement of the central nervous system is even less common. Case presentation: A 46-year-old man suffering from ulcerative colitis and epilepsy was hospitalized in the neurology department due to progressive, ascending paresthesia and quadriplegia accompanied by sphincter and balance disorders. Magnetic resonance imaging revealed extensive edematous changes extending from the medulla oblongata to the Th7 level and multiple enlarged mediastinal lymph nodes. Diagnostic workup was expanded to include a contrast-enhanced computed tomography scan of the chest, which revealed numerous enlarged lymph nodes in the mediastinum and scattered small nodular lesions in the lung parenchyma. After performing a histopathological examination of the subcarinal lymph node biopsy material, a diagnosis of sarcoidosis was made. The patient was diagnosed with longitudinal extensive transverse myelitis (LETM) in the course of probable neurosarcoidosis and was treated showed clinical improvement following treatment. Conclusion: Although central... Continue Reading

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Background: Purulent bacterial pericarditis is an exceptionally rare but rapidly progressive cause of acute pericarditis in the modern antibiotic and pneumococcal vaccination era. Despite its low incidence, delayed recognition carries a high risk of cardiac tamponade, septic shock, constrictive pericarditis, and death. Case Presentation: We report the case of a 64-year-old man with pulmonary and hepatic sarcoidosis and well-controlled human immunodeficiency virus (HIV) infection receiving highly active antiretroviral therapy with an undetectable viral load, who presented with pleuritic chest pain and progressive dyspnea. Initial evaluation demonstrated diffuse ST-segment elevations on electrocardiogram and a moderate pericardial effusion without tamponade physiology on transthoracic echocardiography. Computed tomography revealed multifocal pneumonia, prompting empiric antimicrobial therapy. Despite initial management, the patient rapidly deteriorated with hypotension and acute hypoxic respiratory failure. Repeat echocardiography demonstrated evolving cardiac tamponade, necessitating emergent pericardiocentesis. Blood cultures and pericardial fluid cultures both yielded Streptococcus pneumoniae, confirming purulent pneumococcal pericarditis and allowing... Continue Reading

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Background: Hypertrophic cardiomyopathy (HCM) due to sarcomeric variants shows age-dependent penetrance and wide intrafamilial variability. The MYH7 p.Arg719Gln variant has been labelled “malignant,” a label current guidelines no longer support because genotype is excluded from validated sudden cardiac death (SCD) risk models. Case Presentation: A four-generation Moroccan family was referred after five premature sudden deaths in young relatives. The pathogenic MYH7 c.2156G>A (p.Arg719Gln) variant, first identified in the proband, was found in seven relatives (five female). Only the three adults (all women) met diagnostic criteria for HCM (non-obstructive hypertrophy, maximal septal thickness 15.5–17 mm). The four younger carriers did not: two children had sub-diagnostic septal z-scores (≈1.5 and ≈1.0) and two had no hypertrophy, yet the youngest showed markedly increased ECG voltage out of proportion to wall thickness. Non-carriers were released from surveillance. Conclusion: This family shows both the yield and the limits of cascade testing. Because none of the... Continue Reading

Poisoning with herbicides pose a diagnostic and therapeutic challenges in agricultural settings. Distinct toxicodynamic profiles and management strategies have been described among various major herbicide classes, despite overlapping clinical features. Paraquat is highly lethal herbicide with high mortality rate. Acute liquid herbicide poisonings are frequently presumed to be paraquat because of its high prevalence and notorious mortality rate, creating mis-classification when the actual culprit is 2,4-Dichlorophenoxyacetic acid (2,4-D). Such mis-classification and delayed identification of specific herbicide compound ingested may cause preventable therapeutic errors, particularly delaying urinary alkalinization protocol in 2,4-D poisoning. Therefore, this letter highlights the importance of compound specific management in herbicide poisoning rather than class-based management.  Continue Reading