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Hyperleukocytosis (HL) in acute leukemia is associated with increased morbidity and mortality, mainly secondary to the effects of leukostasis. Many strategies for cytoreduction exist, however prompt initiation of chemotherapy is paramount. Leukapheresis is an additional strategy, though there is conflicting data for its use in HL in acute leukemia. Below we detail a case of HL and leukostasis in newly diagnosed pediatric T-cell acute lymphoblastic leukemia and the use of leukapheresis. We highlight that leukapheresis can rapidly and safely reduce the white blood cell count, as an adjunct to symptom management, and potentially prevent life-threatening complications while not delaying chemotherapy initiation. However, this case underscores that early recognition of HL prior to the development of severe neurological complications is critical, as once cerebral leukostasis with intracranial hemorrhage is established, neither leukapheresis nor chemotherapy may alter the fatal outcome. The patient's initial presentation with epistaxis and hematemesis two days prior-without laboratory evaluation-represents a missed opportunity that may have allowed earlier recognition and intervention.
Methicillin-resistant Staphylococcus aureus infection can cause serious illness in children. It can progress to life-threatening bloodstream issues or bone infections, including: deep vein thrombosis, septic pulmonary embolism, toxic shock syndrome, and osteomyelitis. Treatment depends on control of infection with adequate antibiotics and early anticoagulation. We present a case of a 11-year old male child who presented with left arm and right leg pain and swelling that was associated with fever. However, there was no history of trauma. Blood culture was taken and showed Methicillin-resistant Staphylococcus aureus growth. Initial ultrasound of the affected limbs was unremarkable except for subcutaneous edema. On the following day, ultrasound of the affected limbs was consistent with deep vein thrombosis. Additionally, the patient developed pleuritic chest pain and a computed tomography scan with pulmonary angiography demonstrated a filling defect in the left upper segmental artery suggesting septic pulmonary embolism. Magnetic resonance imaging of the lower limbs was recommended and it suggested the diagnosis of osteomyelitis. Ultrasound guided drainage was done and the patient was treated with appropriate antibiotics and enoxaprine. Multifocal thromboembolic events with osteomyelitis in an immunocompetent child are rare and clinically important. This case highlights the complex nature of methicillin-resistant Staphylococcus aureus infection in pediatrics and emphasizes the value of early imaging and multidisciplinary collaboration to establish an accurate diagnosis and a good clinical outcome. Awareness of such presentations can facilitate earlier diagnosis and intervention, to reduce the risk of complications in pediatric patients.
Cardiac metastases, particularly those originating from non-Hodgkin lymphoma, are often underdiagnosed and represent a rare but critical manifestation of advanced cancer. This case report discusses a 57-year-old female with a history of hypertension who initially presented with symptoms of cardiac tamponade, leading to the discovery of a large cardiac mass, ultimately diagnosed as diffuse large B-cell lymphoma following a cytological examination of the pericardial fluid and lymph node biopsy. Further imaging, including echocardiography and computed tomography scans, showed extensive metastasis to the pericardium, mediastinum, and other areas, such as the thyroid and peritoneum. Despite the prompt initiation of management, the patient suffered a massive pulmonary embolism, highlighting the poor prognosis associated with metastatic cardiac lymphoma. This case underscores the importance of bedside echocardiography as a rapid initial method for identifying cardiac tamponade, as well as maintaining a high index of suspicion for hematologic malignancies in patients presenting with unexplained pericardial effusions. It emphasizes the need for comprehensive diagnostic approaches and multidisciplinary management to improve patient outcomes in this rare and challenging clinical scenario.
May-Thurner Syndrome (MTS) is an underrecognized anatomic cause of left-sided deep vein thrombosis (DVT) resulting from compression of the left common iliac vein by the overlying right common iliac artery. Although it accounts for approximately 2-5% of DVT cases, it may be overlooked when other provoking risk factors are present, leading to incomplete treatment and risk of recurrence. We report a 61-year-old woman with no prior history of venous thromboembolism who presented with one week of progressive left lower extremity swelling and pain following recent femoral venous catheterization during a prior hospitalization. Imaging demonstrated extensive proximal iliofemoral DVT involving the left external iliac, common femoral, and superficial femoral veins. Despite initiation of intravenous anticoagulation, the significant clot burden prompted aspiration mechanical thrombectomy. Post-procedural venography revealed persistent residual stenosis of the left common iliac vein, raising suspicion for underlying iliac vein compression. The distribution of thrombosis and focal stenosis was consistent with MTS. Balloon venoplasty was unsuccessful, and definitive management was achieved with placement of a 16 mm × 80 mm venous stent, resulting in restoration of inline venous flow. The patient was transitioned to oral anticoagulation with dual antiplatelet therapy and experienced clinical improvement without complications. This case highlights MTS as an important and potentially underdiagnosed cause of extensive left-sided DVT, particularly when thrombus burden appears disproportionate to apparent provoking factors. Recognition of this anatomic variant is essential, as anticoagulation alone may be insufficient and endovascular intervention is often required to prevent recurrence and long-term venous morbidity.
Priestia megaterium (formerly Bacillus megaterium) is a Gram-positive, spore-forming environmental bacillus rarely associated with human infection. In this report, we present a case of a rapidly progressive polymicrobial pyogenic liver abscess with subsequent isolation of P. megaterium in a 69-year-old woman with type II diabetes mellitus, chronic kidney disease, metabolic liver disease, and extensive antibiotic allergies. She initially presented with progressive abdominal pain and fever, with negative early imaging studies. Three weeks later, computed tomography (CT) demonstrated new hepatic abscesses. Interventional radiology drainage cultures initially grew Streptococcus intermedius, guiding targeted antimicrobial therapy; however, the patient clinically deteriorated with recurrent abscess formation despite drainage and broad-spectrum coverage. Subsequent aspirate cultures from the abscess fluid later grew P. megaterium, though this result was finalized after the patient's death on day 12 of admission despite intensive care and source control attempts. This case suggests that P. megaterium, traditionally regarded as nonpathogenic, may be recovered in severe infections in immunocompromised hosts; however, alternative explanations-including polymicrobial infection, antibiotic-mediated suppression of co-pathogens, iatrogenic introduction during drainage procedures, or culture contamination-must be carefully considered. Contributing factors likely included her underlying comorbidities, concurrent COVID-19 infection, delayed pathogen identification, and restrictions imposed by multiple drug allergies. Diagnostic challenges underscore the importance of repeated culture sampling, careful interpretation of microbiology results, and awareness of rare organisms when standard therapy is unsuccessful. This report expands the spectrum of diseases associated with P. megaterium. It emphasizes the need for multidisciplinary collaboration and heightened clinical vigilance in cases of rapidly progressive intra-abdominal infections that are unresponsive to conventional treatment.
Boerhaave's syndrome is a rare and life-threatening form of spontaneous esophageal perforation, typically triggered by forceful vomiting and often misdiagnosed due to nonspecific clinical features. Although Mackler's triad (vomiting, chest pain, and subcutaneous emphysema) is classically associated with the condition, it is infrequently observed in full. We present the case of a 32-year-old man with a history of ulcerative colitis (UC) who presented to the emergency department with acute chest pain and repeated vomiting following dinner. He reported a sensation of food impaction and sought care 2 hours after symptom onset. Examination revealed subcutaneous emphysema and abdominal tenderness. Imaging with oral contrast-enhanced computed tomography revealed pneumomediastinum, pneumoperitoneum, and a distal esophageal perforation, confirming Boerhaave's syndrome. He underwent robotic-assisted laparoscopic repair with anterior fundoplication, endoscopic stenting, and drainage. His postoperative course included thoracentesis, IV antibiotics, and a gradual reintroduction of diet. A mild UC flare was managed with mesalamine. He was discharged in stable condition on postoperative day 9 and had full radiologic recovery at 3 months. This case stands out for its complete presentation of Mackler's triad, a rare occurrence that facilitated early diagnosis. The patient's young age and concurrent UC added clinical complexity. Prompt imaging and early minimally invasive surgical management, combined with coordinated multidisciplinary care, were key to a favorable outcome. This case underscores the importance of considering Boerhaave's syndrome in atypical presentations and acting swiftly when classical signs do appear.
Subacute stent thrombosis is an uncommon but life-threatening complication of percutaneous coronary intervention (PCI). While mechanical and antiplatelet-related factors are most frequently implicated, systemic hypercoagulable conditions are increasingly recognized as important contributors. Acute myeloid leukemia (AML) is associated with complex hemostatic abnormalities that may predispose to both venous and arterial thrombosis, particularly in the presence of hyperleukocytosis. We report the case of a 33-year-old male with minimal cardiovascular risk factors who presented with ST-segment elevation myocardial infarction and was found to have a large thrombus burden in the proximal left anterior descending artery. Despite pharmacologic reperfusion and subsequent drug-eluting stent implantation, he re-presented ten days after discharge with subacute stent thrombosis and additional thrombotic involvement of multiple coronary vessels, leading to hemodynamic instability. Although he reported adherence to dual antiplatelet therapy, laboratory evaluation revealed rapidly progressive leukocytosis accompanied by anemia and thrombocytopenia. Further hematologic workup confirmed a diagnosis of acute myeloid leukemia with profound hyperleukocytosis. Cytoreductive therapy was initiated, but the course was complicated by tumor lysis syndrome and acute kidney injury, necessitating renal replacement therapy prior to transfer for definitive oncologic management. This case highlights AML-associated hypercoagulability and hyperleukocytosis as potential contributors to early and recurrent coronary thrombosis following PCI. Leukostasis, endothelial activation, and blast-mediated procoagulant activity likely acted synergistically with stent-related endothelial injury to promote thrombosis despite standard antiplatelet therapy. Early or recurrent stent thrombosis, particularly in younger patients or in the presence of unexplained hematologic abnormalities, should prompt evaluation for underlying malignancy. Recognition of AML in this context is critical, as it may influence revascularization strategy, antithrombotic management, and overall prognosis.
Penile squamous cell carcinoma (PSCC) is a rare presentation in the United States and Europe, accounting for only 1% of male malignancies. Most commonly due to human papilloma virus (HPV), PSCC has an insidious onset, often ignored by patients until functional impairments are present. This report outlines an interesting presentation of penile squamous cell carcinoma while focusing on current developments in the prognosis and treatment of PSCC. We present the case of a 68-year-old male who presented with a 5 cm fungating mass of the glans penis after emergent care following a stroke. Visual inspection revealed a large mass of the glans penis which had completely obliterated the urethral meatus. A partial penectomy and urethrostomy were performed. Surgical excision revealed a unifocal moderately differentiated (G2) squamous cell carcinoma, with immunohistochemical staining demonstrating p16 positivity, consistent with HPV-associated etiology. This case highlights the importance of individualized treatment regimens and prognostic determination for optimal patient outcomes.
Melanoma is an aggressive malignancy with a high propensity for metastasis; however, clinically apparent involvement of the gastrointestinal tract is uncommon. We report a case of metastatic melanoma involving the stomach that presented as gastrointestinal bleeding shortly after initial diagnosis. A patient with recently diagnosed melanoma with nodal metastasis presented with melena and symptomatic anemia. Esophagogastroduodenoscopy revealed multiple gastric mucosal lesions that were notably amelanotic, lacking the characteristic pigmentation typically associated with melanoma. Histopathological and immunohistochemical evaluation confirmed metastatic melanoma, and imaging findings were concerning for advanced disease. The presence of pneumatosis raised suspicion for mucosal compromise and possible early perforation, highlighting the potential severity of gastrointestinal involvement. Gastrointestinal metastases from melanoma are often clinically silent and may present with nonspecific symptoms, leading to delayed diagnosis. This case is notable for early symptomatic presentation and the presence of amelanotic lesions, which may be easily overlooked during endoscopic evaluation. The absence of pigmentation can pose a diagnostic challenge and requires a high index of suspicion in patients with a history of melanoma. Early endoscopic evaluation and tissue diagnosis are essential for timely recognition and management. Clinicians should maintain a high index of suspicion for gastrointestinal metastases in melanoma patients presenting with unexplained anemia or bleeding, even in the absence of classic endoscopic features.
Acute promyelocytic leukemia (APML) is a rare hematologic emergency with a high mortality rate due to bleeding diathesis, which is due to a disseminated intravascular coagulation-like coagulopathy; APML is complicated enough to treat on its own and becomes particularly challenging when it occurs during pregnancy due to the complexities in managing both maternal and fetal health. APML is associated with a challenging therapeutic dilemma for pregnant women, and there is a risk of fetal malformations and developmental abnormalities caused by exposure to chemotherapy. A 31-year-old woman at 29 weeks of gestation presented with a 3-week history of fatigue. Complete blood count revealed pancytopenia, and further evaluation confirmed a diagnosis of APML. Due to her severe thrombocytopenia and associated pregnancy risks, ATRA therapy was initiated, and a primary Cesarean section was performed at 31 weeks 3 days of gestation to mitigate maternal and fetal complications. After delivery, arsenic trioxide was added to the treatment regimen, resulting in a favorable response. In this case report, we discuss clinical decisions and therapeutic interventions and compare our patient's case with those found in the literature. This case highlights the importance of prenatal care and early intervention in improving outcomes for both mother and child.
Vitamin B12 deficiency is classically associated with megaloblastic anemia and neurologic or neuropsychiatric manifestations; however, in rare cases, it may present with pancytopenia and laboratory features that mimic hemolytic anemia. Pernicious anemia is a common cause of vitamin B12 deficiency classically described in older adults of Northern European descent; however, it can occur across all ages and ethnic backgrounds, and demographic assumptions should not delay diagnosis. We report a 35-year-old African American man with no significant past medical history who presented with progressive weakness, decreased appetite, and fatigue. Initial laboratory evaluation revealed profound macrocytic anemia, thrombocytopenia, elevated lactate dehydrogenase, indirect hyperbilirubinemia, and low haptoglobin. Despite these findings, the reticulocyte response was inappropriately low, the direct antiglobulin test was negative, and the peripheral blood smear demonstrated no schistocytes, consistent with ineffective erythropoiesis rather than true hemolysis. Further evaluation revealed severe vitamin B12 deficiency with normal folate levels and positive intrinsic factor antibodies, and biopsy findings consistent with autoimmune metaplastic atrophic gastritis supporting a diagnosis of pernicious anemia. Treatment with intramuscular vitamin B12 resulted in rapid clinical and hematologic improvement, emphasizing the reversibility of hematologic manifestations with prompt therapy. This case highlights pernicious anemia as a reversible cause of pseudo-hemolytic anemia and underscores the importance of recognizing its distinguishing features to avoid unnecessary interventions such as plasma exchange or immunosuppressive therapy.
Infective manifestations of hematological malignancies can be traced to a variety of pathogens, necessitating broad spectrum empiric antibiotic coverage, and prompt identification of pathogenic microbes to improve clinical outcomes. We present a case of Morganella morganii leading to pneumonia as the presenting illness in a previously undiagnosed, functionally neutropenic adult presenting with acute myeloid leukemia with monocytic differentiation. Our patient was a 64 year old man with no prior medical care who presented with complaints of progressive abdominal pain, productive cough and fevers. Chest radiography revealed no organized consolidations, and computed tomographic imaging of the chest showed bibasilar atelectasis and trace pleural effusions. Laboratory analysis revealed marked leukocytosis with predominant monocytosis, and circulating blasts, suggestive of acute myeloid leukemia with monocytic differentiation, later confirmed with bone marrow biopsy. The patient was initially started on guideline directed empiric therapy for respiratory infection, with sputum cultures later found to be growing Morganella morganii, necessitating a change in antimicrobial therapy, following which the patient showed clinical improvement. To our knowledge, this is the first reported case of Morganella morganii pneumonia presenting at the initial diagnostic encounter of de novo acute myelomonocytic leukemia. This report underscores the need for prompt microbiologic evaluation, broad empiric coverage with early de-escalation, and inclusion of M. morganii in the differential diagnosis of pneumonia in functionally neutropenic patients when standard pathogens are not identified. This case highlights the need to recognize atypical Gram-negative organisms as potential pathogens in these populations, even in the absence of characteristic radiographic findings.
Noni (Morinda citrifolia) is a widely plant-based herbal product with purported antioxidant, anti-inflammatory, and immunomodulatory properties and is widely available in oral, liquid, and topical formulations. Hepatotoxicity from juice and oral formulations are infrequent and liver injury associated with topical noni exposure has not previously been described. We report the case of a 60-year-old male with a history of hypertension and hypothyroidism who presented with 5 days of jaundice, generalized pruritus, dark urine, and acholic stools. Laboratory evaluation showed elevated liver enzymes in a cholestatic pattern. The patient reported prolonged use of a topical noni-containing analgesic cream for approximately 8 months, which had been discontinued 3 months prior to symptom onset. A through diagnostic evaluation excluded viral, autoimmune, and metabolic etiologies of the liver disease. Given the exposure history, clinical presentation, and exclusion of alternative diagnoses, the drug-induced liver injury was attributed to the topical noni product. The management included close outpatient follow-up until resolution of liver function tests 6 months after discharge after the discontinuation of the product. The precise mechanism for noni toxicity remains unclear, but a potential proposed pathway includes anthraquinone-mediated oxidative stress with subsequent mitochondrial dysfunction, but further investigation is warranted to better characterize systemic absorption and hepatotoxic risk associated with topical noni formulations.
Epilepsia partialis continua is an uncommon form of focal status epilepticus characterized by continuous focal motor activity with preserved awareness. In adolescents with psychiatric comorbidity, these movements may be mistaken for functional or compulsive behavior, a phenomenon that may reflect diagnostic overshadowing, the misattribution of neurological or medical symptoms to a preexisting psychiatric condition. A 15-year-old boy with anxiety disorder, obsessive compulsive disorder, and panic disorder presented with a two week history of persistent right toe and foot tapping that spread proximally and became painful. His family reported that the movements continued during sleep, although inpatient observation showed that they occasionally paused or disappeared. This inconsistency contributed to an early impression of a psychogenic process and led to the deferral of neuroimaging. Continuous video EEG subsequently demonstrated frequent, rapidly recurring epileptiform discharges over the left central region that corresponded to the right foot movements, confirming epilepsia partialis continua. Treatment with lacosamide and clobazam led to complete resolution of the movements and pain within 24 hours. Subsequent brain MRI was unremarkable, and symptoms remained controlled on follow up. This case illustrates how psychiatric history can shape diagnostic reasoning and delay recognition of epilepsia partialis continua. Persistent focal motor activity, even when intermittently suppressible or behaviorally ambiguous, should prompt early consideration of this diagnosis and escalation to prolonged video EEG when routine evaluation is inconclusive, enabling accurate diagnosis and effective seizure control.
Neuroendocrine tumors (NETs) represent neoplastic growths that arise from cells of neuroendocrine differentiation. They constitute a clinical spectrum from low-grade NETs with an indolent course to the aggressive undifferentiated high-grade neuroendocrine carcinoma. We report a rare case of axillary neuroendocrine carcinoma of unknown primary site. The patient underwent axillary nodal excision followed by radiation therapy with good tolerability. However, distant cerebellar metastatic recurrence was evident 9 months later. We additionally review the literature on cases of axillary NETs. Their heterogenous behavior depict the need for strict clinical surveillance to allow for early identification of occult secondary metastasis and improve prognostic outcomes.
Aggressive seropositive rheumatoid arthritis (RA) typically manifests with marginal joint erosions and periarticular osteopenia but rarely presents with diffuse osteolytic lesions mimicking malignancy. A 65-year-old woman presented with subacute back pain and incidentally discovered hypercalcemia (calcium 12.7 mg/dL). Imaging revealed multifocal lytic lesions of the axial and appendicular skeleton highly suggestive of multiple myeloma or metastatic disease, along with supraclavicular lymphadenopathy. Extensive evaluation including bone marrow biopsy demonstrated polyclonal plasmacytosis without evidence of hematologic malignancy. Lymph node excision revealed reactive follicular hyperplasia. Subsequent rheumatologic assessment identified symmetric inflammatory polyarthritis, rheumatoid nodules, rheumatoid factor 191 IU/mL, and anti-cyclic citrullinated peptide (anti-CCP) antibodies 2630 U/mL, establishing the diagnosis of aggressive seropositive RA. Bursectomy of a right elbow mass confirmed necrobiotic granulomatous inflammation consistent with a rheumatoid nodule. Treatment with methotrexate, leflunomide, and rituximab led to resolution of hypercalcemia, substantial improvement in joint symptoms, and radiographic stabilization of lytic lesions. This case highlights how RANKL-mediated osteoclast activation and anti-CCP antibody-driven bone resorption can, in rare instances, produce malignancy-mimicking diffuse osteolysis and hypercalcemia, and underscores the importance of considering RA in the differential diagnosis of diffuse lytic bone lesions. The diagnosis was supported by fulfillment of 2010 ACR/EULAR classification criteria, histologic confirmation of rheumatoid nodules, and dramatic response to disease-modifying antirheumatic therapy.
Griscelli syndrome type 2 (GS2) is a rare autosomal recessive immunodeficiency disorder characterized by silver-colored hair, fair skin, and an increased risk of developing hemophagocytic lymphohistiocytosis (HLH). Systemic juvenile idiopathic arthritis (sJIA) is an autoinflammatory condition distinguished by daily fevers, transient rash, and arthritis, with macrophage activation syndrome being a known complication. We present a case involving an 18-month-old female with persistent fever, rash, and joint inflammation. Laboratory findings revealed elevated inflammatory markers and hyperferritinemia, prompting concern for HLH, though full diagnostic criteria were not satisfied. A unique clinical sign led to extended evaluation, and genetic testing confirmed the presence of GS2. Concurrent clinical features also met the requirements for sJIA. To the best of our knowledge, this is the first reported instance of GS2 co-occurring with sJIA. This case highlights a potential shared susceptibility to immune dysregulation and raises the possibility that immunodeficiency may reveal or influence the manifestation of autoinflammatory diseases. Prompt recognition is essential in managing atypical and treatment-resistant inflammatory presentations.
Low platelet count is rarely caused by inherited thrombocytopenia. May-Hegglin anomaly is an uncommon condition that falls under the umbrella of familial thrombocytopenia. The condition is under-reported in Saudi Arabia; therefore, we report the current case. This is a 24-year-old Saudi lady, presented to the emergency room with vaginal bleeding. No bleeding occurred at any other sites. She has a positive family history of thrombocytopenia among her father and 2 of her siblings. Her platelet count was 16 × 103/µL with normal other blood count as well as renal and liver panels. She was admitted to the regular bed for investigation as sever thrombocytopenia with suspicion of either familial or immune thrombocytopenia. Further studies showed normal hemostatic, virology, and connective tissue disease markers. Peripheral blood film showed low platelet distribution with occasional large/giant platelets and basophilic inclusion bodies in some neutrophils (Dohle body-like). A picture suggestive of May-Hegglin related thrombocytopenia that was confirmed by the presence of a positive myosin heavy chain 9 (MYH9) gene mutation. In conclusion, there are many difficulties in diagnosing and treating May-Hegglin disorders in females of reproductive age. More research and guidelines are needed to manage inherited thrombocytopenia before and throughout pregnancy.
Large B-cell lymphoma (LBCL) with IRF4/MUM1 rearrangement is a rare and newly recognized entity predominantly involving Waldeyer's ring of lymphoid tissue in the oropharynx. Unusual clinical presentations can result in delayed diagnosis of LBCL with IRF4 rearrangement, resulting in increased patient morbidity. We present a case involving a pregnant woman with a frontal sinus swelling and clinical diagnosis of chronic sinusitis and possible Pott's puffy tumor. An endoscopic procedure and subsequent histologic examination revealed diffuse LBCL with diffuse IRF4/MUM1 staining, supported by fluorescence in situ hybridization analysis showing an IRF4 locus rearrangement at 6p25.3. Subsequent imaging revealed metastatic disease to cervical, thoracic, and lumbar spinal regions. This case highlights the importance of consideration of lymphomas in patients who may clinically appear to have non-neoplastic disease, especially in the head and neck regions.
Hemorrhagic central nervous system (CNS) metastases are well recognized in melanoma yet seldom represent the initial manifestation, and fulminant, steroid-refractory hepatitis from immune checkpoint inhibitors (ICIs) remains exceedingly rare. Here, we present a 54-year-old man with no prior medical history who was brought to the emergency department with acute confusion and aphasia and was found to have a large right frontal hemorrhagic mass with midline shift. Urgent craniotomy and hematoma evacuation revealed high-grade melanoma, BRAF V600-negative. Imaging identified stage IV disease with pulmonary and hepatic metastases. He was started on ipilimumab and nivolumab combination therapy outpatient; however, treatment was held after 2 cycles due to marked transaminitis, and prednisone was initiated for presumed ICI-related hepatitis. Despite corticosteroids, liver function progressively worsened over the following weeks, which required a second hospitalization and culminated in fulminant liver failure and encephalopathy. High-dose methylprednisolone offered minimal improvement. Although second-line immunosuppressants were considered, rapid deterioration prompted initiation of tocilizumab. His hospitalization was complicated by multiorgan failure and radiographic progression of CNS metastases, and he ultimately transitioned to comfort care and died on hospital day 7. This case demonstrates hemorrhagic CNS disease at diagnosis alongside early, fulminant, steroid-refractory ICI hepatitis and highlights the need for heightened hepatic surveillance and early escalation of immunosuppression during dual checkpoint blockade.