IgG4-related autoimmune diseases (IgG4 RD) are a relatively recently recognised group of disease processes that can affect multiple organ systems and result in protean symptoms. Here, we present a rare case of a 69-year-old man with a history of IgG4 RD affecting his lacrimal gland and pancreas who developed symptoms of severe laryngitis not responsive to usual therapy. He presented with non-productive cough, hoarseness and dyspnoea. Imaging findings suggestive of aortitis and laryngeal inflammation in the setting of his IgG4 RD history prompted treatment with rituximab, which resulted in resolution of his laryngeal symptoms. Subsequently, his cough returned and he required periodic rituximab infusions to stay symptom-free. IgG4 RD of the larynx is an uncommonly reported manifestation in literature. This disease is very responsive to anti-CD20 monoclonal antibody treatment. IgG4 RD should be considered in patients with airway symptoms that are especially refractory to usual therapy.

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.

INTRODUCTION: Ischemic Colitis (IC) is the most common form of intestinal ischemic disorders. This disease process typically affects older adults and is the result of non-occlusive hypoperfusion, which can be precipitated by a multitude of risk factors. Patients usually present with lower abdominal pain and hematochezia. A colonoscopy with biopsies is the gold standard for diagnosis. Increasingly, medications have been associated with contributing to this disease process. Here, we report a unique case of IC attributed to Docetaxel, a taxane class chemotherapeutic agent. CASE DESCRIPTION/METHODS: A 76-year-old Caucasian female with a history of multi-focal intraductal carcinoma (Stage IIA), hypertension, and diverticulosis presented to the emergency room (ER) with complaints of lower back and abdominal pain. She had begun therapy with Docetaxel and Cyclophosphamide 8 days prior to presentation. In the ER, she was afebrile, neutropenic (ANC 400), and hypotensive requiring supportive care including antibiotics, fluids and a very brief course of norepinephrine. She was subsequently admitted to the intensive care unit where her neutropenia was noted to have resolved and antibiotics were discontinued in setting of negative cultures. On hospital day 3, she complained of continued abdominal pain and hematochezia with CT imaging that demonstrated bowel wall thickening and mild inflammatory changes in the sigmoid/descending colon. Subsequently, a colonoscopy was performed and showed circumferential, violaceous mucosa consistent with IC. Antibiotics were restarted and the patient was treated supportively with complete resolution of symptoms. Following hospital discharge, she was evaluated by her oncologist who discontinued her Docetaxel and initiated therapy with Paclitaxel. No recurrence of her symptoms have been noted and repeat cross sectional imaging demonstrated resolution of colonic thickening in the previously noted watershed distribution. DISCUSSION: IC is a rare but serious complication that has been described in patients receiving Docetaxel. Among the 6 reported cases, symptoms occur within 10 days of Docetaxel administration. Patients present with abdominal pain and hematochezia in the setting of neutropenia with or without fever. This type of IC is often severe, with spontaneous perforation, bowel necrosis, and a reported mortality rate of 40-50%. Although underreported, Docetaxel use is a risk factor for developing IC, one deserving of more clinical awareness.

Introduction: Polyethylene glycol 3350 and electrolytes (PEG) is a perceived safe and commonly prescribed solution prior to colonoscopy, yet case reports suggest the potential for volume overload. We describe a patient with cardiopulmonary comorbidities who developed pulmonary edema and acute hypoxic respiratory failure (AHRF) due to PEG administration. Case Description/Methods: A 55-year-old man with interstitial lung disease (ILD), mild pulmonary hypertension (pHTN), and coronary artery disease (CAD) with multiple coronary stents was admitted to our tertiary academic hospital with cough and constitutional symptoms. He had a brain natriuretic peptide (BNP) of 50 pg/mL, was found to be in AHRF and intubated due to labored breathing. He received broadspectrum antibiotics and corticosteroids with clinical improvement and within 4 days was extubated. Given his severe ILD, he was evaluated for lung transplant. As part of this evaluation, mandatory colon cancer screening was needed in the form of computed tomography (CT) colonography. He had difficulty consuming Golytely at an appropriate rate. Despite 16 liters (L) of PEG over 3 days, the stools were not clear. He then re-developed hypoxia and tachypnea and BNP rise to 475 pg/mL. Chest X-ray (CXR) showed new bilateral opacities concerning for pulmonary edema. Echocardiography demonstrated an IVC greater than 2.0 cm without respiratory variation consistent with volume overload. His bowel prep was held, and he was given diuretics with improvement in his respiratory status, BNP, and CXR. The patient was re-trialed on 6L PEG by nasogastric tube successfully without cardiopulmonary complications and his CT colonography showed no colonic polyps or malignancy. He eventually underwent successful bilateral orthotopic lung transplant. Discussion: Prior research has shown that consumption of 6-8 L of PEG increases mean plasma volume by 5.88% on average, but up to 29.8% in some patients. In this case, our patient consumed double that amount of PEG, with subsequent increase in plasma volume, resulting in pulmonary edema and AHRF due to limited respiratory reserve from his severe ILD, pHTN, and CAD. Literature review shows less than 10 cases worldwide with similar findings. In high-risk patients such as the one described, providers must consider judicious use of PEG for colonoscopy preparation and be quick to identify PEG-associated pulmonary edema as an etiology for respiratory decompensation.

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