Medication adjustments for HTN and T2DM made immediately in the postoperative period following SG persisted throughout the 6-month follow-up period and in some patients, required further adjustments.
A 71-year-old man with a history of asthma and gastroesophageal reflux disease (GERD) presented to the emergency department (ED) with a chief complaint of new-onset right-sided abdominal tenderness attributed to chronic cough. Over the past 2 months, he had been treated with a proton pump inhibitor, leukotriene antagonist, and inhaled steroid without improvement. He also endorsed a 14-pound weight loss.On presentation to the ED, laboratory test results were significant for a new elevation in liver-associated enzymes (aspartate transaminase 60 U/L and alanine transaminase 85 U/L), prompting right-upper quadrant ultrasound evaluation. The ultrasound revealed innumerable solid lesions within the liver, and a subsequent thoracic, abdominal, and pelvic computed tomography showed a 1.9-cm 3 6.1-cm mass within the distal esophagus. The patient was admitted for expedited workup of suspected malignancy.An esophagogastroduodenoscopy (EGD) was performed which revealed a pigmented mass in the distal esophagus (Figure 1). The lesion had a vascular appearance, so biopsies were taken from the periphery of the mass and opposite wall; these demonstrated melanocytic proliferation but did not establish the diagnosis of malignant melanoma (Figure 2). Interventional radiology-guided biopsies of the liver confirmed the diagnosis of metastatic malignant melanoma. The patient was diagnosed with T4bN3M1a BRAF-negative metastatic melanoma involving the esophagus, liver, mesentery, and lumbar spine. Detailed skin examination and formal ophthalmology evaluation did not reveal any primary lesions, establishing the diagnosis of primary malignant melanoma of the esophagus (PMME).Given his metastatic disease burden, radical esophagectomy, the standard treatment for PMME, could not be performed. He was treated with 1 cycle of dual checkpoint inhibitor therapy with ipilimumab and nivolumab, a CTLA-4 and PD-1 inhibitor. The treatment course was complicated by autoimmune hepatitis. The patient declined additional chemotherapy, and he transitioned to comfort care. Figure 1. (A and B): Hyperpigmented mass in the distal esophagus from esophagogastroduodenoscopy.
The use of biologic therapies continues to become more prevalent in the treatment of inflammatory bowel disease, particularly for more severe disease. Although generally safe and effective, specific biologic classes such as tumor necrosis factor inhibitor (anti-TNF) medications are known to increase the risk of certain cancers. Glioblastoma multiforme (GBM) is an aggressive brain tumor which tends to arise sporadically but may be associated with anti-TNF therapies. Here, we present a case of a 69-year-old male with Crohn’s disease who developed GBM while on adalimumab therapy. This case report highlights the potential rare association between GBM and anti-TNF therapy and further discusses the difficulty of managing active Crohn’s disease with concomitant GBM, specifically the difficulty encountered in managing a disease flare.
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