EM Quick Hits 32 Checkpoint Inhibitors, Adult Epiglotitits, HSP, Heat Stroke, Bell’s Palsy and Leukemia

Topics in this EM Quick Hits podcast Walter Himmel on new diseases associated with immune checkpoint inhibitors (00:54) Leeor Sommer on the evolution of epiglottitis - adult epiglottitis clinical pearls (15:40) Sarah Reid on how to pick up HSP (23:12) Anand Swaminathan on an approach to management of heat stroke (31:02) Justin Morgenstern on the association between pediatric Bell's palsy and leukemia (37:12) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Anton Helman Cite this podcast as: Helman, A. Morgenstern, J. Himmel, W. Sommer, L. Reid, S. Swaminathan, A, H. EM Quick Hits 32 - Checkpoint Inhibitors, Adult Epiglottis, HSP, Heat Stroke, Bell's Palsy and Leukemia. Emergency Medicine Cases. August 2021. https://emergencymedicinecases.com/em-quick-hits-september-2021/. Accessed [date]. Checkpoint inhibitors and their immune related diseases: What we need to know about the "mabs" * Checkpoint inhibitors (easily identified on a patient's medication list as they end in the syllable "mab") are immunotherapy drugs that have been shown to be effective in treating some malignancies such as melanoma * They cause immunosuppression which can lead to inflammatory conditions such as dermatitis, colitis, myocarditis, iritis, arthritis, pneumonitis, thyroiditis and aseptic meningitis * The first presentation of these checkpoint inhibitor related inflammatory conditions are often dermatologic (eg. eczema, DRESS syndrome, Stephens-Johnsons) usually 2-4 weeks after starting the checkpoint inhibitor or gastroenterologic (e.g. colitis); other "mab"-related disease may present months after starting the medication * The management of these diseases usually involves stopping the checkpoint inhibitor, starting steroids and consulting their oncologist Expand to view reference list König D, Läubli H: Mechanisms of Immune-Related Complications in Cancer Patients Treated with Immune Checkpoint Inhibitors. Pharmacology 2021;106:123-136. The evolution of epiglottitis to an adult disease - key clinical pearls * Epiglottitis is an adult disease: while epiglottitis has been classically taught as an acute onset, rapidly progressive pediatric emergency with obvious clinical features, in the post-H.Influenza vaccine era, epiglottitis has emerged as an uncommon (1-3 per 100,000 patient encounters) predominantly adult disease with an indolent onset (usually present on day 3 or 4 of illness) that may present to the ED with subtle findings and be more difficult to diagnose, but carries a higher mortality rate in adults than in children * The predominant complaint is sore throat in 94% of patients, 80% dysphagia/odonophaagia, 60% fever * The symptom that should raise your suspicion of epiglottitis is throat pain out of proportion to minimal/no pharyngeal findings * Other useful clues include choking sensation on lying supine and "hot potato" voice * The use of flexible nasopharyngoscopy to directly visualize the "cherry-red" swollen epiglottis is invaluable in making the diagnosis in the ED and is recommended by our expert to be a core competency skill in our training programs; direct laryngoscopy is an alternative modality to directly visua...