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Background: Chest pain is the communal complaint among pediatric age groups. Chest pain due to heart disease is rare in children and adolescents, with an incidence of less than 6%. History and physical examination may be sufficient to identify the most important etiologies. Aim: The aim of the study is to review various causes of chest pain in young patients admitted to a pediatric cardiology clinic. Method: We retrospectively analyzed the clinical data of our patients visited to emergency or outpatient clinics in our hospital with chest pain from March 2022 to October 2022. A total of 56 patients (36 females and 20 males), aged 5-15 years were included in this study. Follow-up of the patients was carried out by calling all relatives of the patient and asking about the child's condition and chest pain. Clinical history and physical examination were performed. Results: A total of 56 patients between the ages of 5 and 15 were enrolled in the study, with a mean age of 11.78 ± 2.95 years. Six cases (10.7%) were identified to have a cardiac cause. 16 individuals (28.6%) had a respiratory cause identified. 3(5.4%) of patients referred to a gastroenterology clinic with gastrointestinal causes. The diagnosis of idiopathic chest pain was made in 6 individuals (10.7%) after a negative history, physical examination, and testing. Conclusion: Chest pain in children is usually mild. However, thorough physical examination and detailed history should be performed to detect any signs of disease. Keywords: Chest pain, Pediatric patients, Echocardiography.

Background In the solid organ transplant (SOT) population, West Nile virus (WNV) neuroinvasive disease can have significant morbidity and mortality. We evaluated cerebrospinal fluid (CSF) findings in neuroinvasive WNv infections among SOT recipients. Methods We retrospectively reviewed medical records of all SOT recipients at our institution with WNv neuroinvasive disease (meningitis, encephalitis, meningo-encephalitis) from 2010 to 2018. Descriptive statistics were examined on key variables. Results Eight transplant patients with mean age 54.47 years (12.79) were included: 5 kidney transplants, 1 in each kidney-pancreas, liver and lung transplants. Median time from transplant to infection was 49.8 months (2.7-175.4) and mean time-to-diagnosis 2 days (1.31) . On admission, mean total CSF WBC count was 134.57 cells/mm3 (150.82), mean lymphocyte count 56.29 cells/mm3 (32.32), mean neutrophil count 27.14 cells/mm3 (34.34), and mean CSF protein 95.4 mg/dL (40.52mg/dL). West Nile virus CSF IgG at the time of diagnosis was negative in 7 patients, and not performed on 1 patient. WNv diagnosis is depicted below. Serum and CSF WNV Antibodies in Neuroinvasive Disease in SOT Recipients WNV CSF and serum IgG was negative at the time of diagnosis in 7/8 patients. Initial CSF IgM was positive in 3 out of 7 patients. Conclusion WNv infection produces a CSF pleocytosis with neutrophilic predominance, though we noted more lymphocytic predominance among SOT recipients. CSF IgM and IgG are important diagnostics in neuroinvasive WNv. Disclosures Diana F. Florescu, MD, AlloVir: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support|NobelPharma: Grant/Research Support|Novavax: Grant/Research Support|Regeneron: Grant/Research Support|SymBio: Grant/Research Support|Takeda: Advisor/Consultant|Takeda: Grant/Research Support.

Hemophagocytic lymph histiocytosis (HLH) is not an independent disease but is instead a clinical syndrome that occurs in many underlying conditions involving all age groups. HLH is the consequence of a severe, uncontrolled hyperinflammatory reaction that in most cases is triggered by an infectious agent. Acquired HLH is much more common than primary HLH syndrome but primary is more fatal, and it does have the worst prognosis with no definitive treatment available to date. This review article mentioned all the latest advancements regarding etiologies, pathogenesis, treatment, and outcomes in critically ill patients who got diagnosed with HLH syndrome in last 15 years.

West Nile virus (WNv) is a major cause of viral encephalitis in the United States. WNv infection is usually asymptomatic or a limited febrile illness in the immunocompetent hosts, although a small percentage can develop neuroinvasive disease. Neuroinvasive disease due to WNv in solid organ transplant recipients occurs at higher rates than observed in the general population and can have long term neurological sequalae.We retrospectively reviewed medical records of all solid organ transplant recipients at our institution who tested positive for WNv from 2010 to 2018. Two reviewers performed electronic searches of Medline, Embase, Cochrane Library of literature of WNv infections in SOT. Descriptive statistics were performed on key variables.Eight recipients (mean age 54, five males) were diagnosed with neuroinvasive WNv infection at our institution. Distribution of infection was as follows: five kidney transplants, one in each kidney-pancreas, liver, and lung. Diagnoses included meningitis (3), encephalitis (1), meningo-encephalitis (4). Median time from transplant to infection was 49.8 months (2.7-175.4). No infections were considered donor-derived. Five patients received treatment with IVIG. Six patients were alive at median follow-up of 49.5 months (21.7-116.8). We identified 29 studies published from 2002 to 2019. Median time from transplant to infection was 14.2 months, with similar allograft distribution; 53% were donor-derived infections.WNv infections in solid organ transplant recipients can be a consequence of organ donation or can be acquired via the community. Infections can be more severe in SOT recipients and lead to neuroinvasive disease.

Cancer is a category of disorders characterized by excessive cell proliferation with the ability to infiltrate or disseminate to other organs of the body. Mitochondrial dysfunction, as one of the most prominent hallmarks of cancer cells, has been related to the onset and development of various cancers. Mitofusin 2 (MFN2) is a major mediator of mitochondrial fusion, endoplasmic reticulum (ER)-mitochondria interaction, mitophagy and axonal transport of mitochondria. Available data have shown that MFN2, which its alterations have been associated with mitochondrial dysfunction, could affect cancer initiation and progression. In fact, it showed that MFN2 may have a double-edged sword effect on cancer fate. Precisely, it demonstrated that MFN2, as a tumor suppressor, induces cancer cell apoptosis and inhibits cell proliferation via Ca

Beta-lactam allergies (BLAs) are common in hospitalized patients, including transplant recipients. BLA is associated with decreased use of preferred surgical site infection (SSI) prophylaxis and increased SSIs, but this has not been studied in the transplant population.We reviewed adult heart, kidney, and liver transplant recipients between January 1, 2016 and December 31, 2019 to characterize reported BLA and collect SSI prophylaxis regimens at time of transplant. We compared the use of preferred SSI prophylaxis and SSI incidence based on reported BLA status. Post hoc we collected antibiotic days of therapy (DOT) (excluding pneumocystis prophylaxis) in the 30-day period posttransplant for patients without SSI. We utilized descriptive statistics for comparisons.Of 691 patients included (116 heart, 400 kidney, and 175 liver transplant recipients), 118 (17%) reported BLA. Rash and hives were the two most reported BLA reactions (36% and 24%), categorized as potential T-cell mediated and IgE mediated, respectively. Preferred SSI prophylaxis was prescribed in 13 (11%) patients with BLA and 573 (92%) without BLA (p.001). No difference could be detected in SSI incidence between BLA and non-BLA patients (4.2 vs. 4.3%, p = 1.0). Of 659 without SSI, 169 (25.6%) received antibiotics within 30 days of transplant; mean antibiotic DOT for BLA and non-BLA patients were 3.5 ± 8.0 versus 2.3 ± 5.8, p = .12.BLA transplant recipients received nonpreferred SSI prophylaxis more frequently than non-BLA recipients, but there was no difference in 30-day SSIs between the groups. One-fourth of solid organ transplant recipients received systemic antibiotics within 30 days of transplant.

Objective: To assess the severity of ulcerative colitis on first colonoscopic examination. Study Design: Prospective cross-sectional (correlational) study design. Place and Duration of Study: Study was conducted in Gastroenterology Outpatient Department of Pak Emirates Military Hospital, Rawalpindi, from Nov 2017 to Oct 2018. Methodology: An aggregate of 200 patients within the age range of 12-70 years, were included in the studythrough non-probability consecutive sampling. The data was collected by the self-administered questionnaireincluding age, gender, stool frequency, P/R bleed, systemic features of ulcerative colitis & colonoscopic findings.Effectiveness of the procedures was noted on a pre-designed performa and the endoscopic assessment was based upon mayo score severity of colitis graded from Normal (0) to Severe (3). Data was analyzed by using SPSS-19. Results: The mean age of the participants was reported 38 ± 2.1 years. Out of 200 participants 104 (52%) weremale, diarrhea with PR bleed was positive in 180 (90%) & anemia in 154 (77%). Colonoscopic findings showedthat 72 (36%) were with Left sided colitis (Montreal Class E2) & 82 (41%) with proctitis (Montreal class E1). Severe disease (Mayo endoscopic Score 3) was positive in 118 (59%) patients. Conclusion: Assessment of severity of UC is important as it determines the long term management & alsovaluable for risk stratification to predict the prognosis. Our findings feature the requirement for system levelenhancements to encourage the proper delivery of colonoscopy services dependent on individual risk. Keywords: , , , .

Objective: To look for frequency and associated socio-demographic factors of newly diagnosed patients of heap-tocellular carcinoma (HCC) among patients treated adequately for hepatitis C infection. Study Design: Correlational study. Place and Duration of Study: Gastroenterology Department, Pak Emirates Military Hospital Rawalpindi, from Nov 2017 to Oct 2018. Methodology: This analysis was performed on 170 patients treated effectively for hepatitis C with standard anti-viral therapy at our hospital. They were followed up for two years after the sustained viral response has been achieved. Ultrasonography was done in all cases and contrast enhanced computerized tomography scan done on patients who were positive on ultrasound. Factors like age, gender, genotype of heaptocellular carcinoma, presence of cirrhosis and model for end-stage liver disease (MELD) score were related with presence of heaptocellular carcinoma among the target population. Results: Out of 170 patients included in final analysis 121 were male, 49 were female. About 53 patients were diagnosed as suffering from heaptocellular carcinoma while 117 were negative for that. Thirty six patients had cirrhosis while 134 non cirrhotic. After applying the binary logistic regression genotypes other than 3, high model for end-stage liver disease score & presence of cirrhosis had a strong relationship with presence of heaptocellular carcinoma among the patients treated for hepatitis C virus. Conclusion: Physicians and patients cannot ignore the possibility of a malignant outcome even after successful treatment of hepatitis C. Local protocols should be set for screening especially the high risk cases even after treatment of hepatitis C virus with special attention to patients with genotype other than 3, cirrhosis & high model for end-stage liver disease score on follow up visits.

Background Antibiotic overuse increases health care cost and promotes antimicrobial resistance. People with HIV (PWH) who develop acute respiratory infections (ARIs) may be assumed to be “higher risk,” compared with non-PWH, but comparative antibiotic use evaluations have not been performed. Methods This observational, single-center study compared antibiotic prescribing in independent clinical encounters for PWH and non-PWH diagnosed with ARI in outpatient clinical practices using International Classification of Diseases, 10th Revision, codes between January 1, 2014, and April 30, 2018. The Fisher exact test compared categorical variables with antibiotic prescribing patterns. Results There were 209 patients in the PWH cohort vs 398 patients in the non-PWH cohort. PWH had a median CD4+ count of 610 cells/mm3, with 91% on antiretroviral therapy and 78% virally suppressed. Thirty-seven percent of all visits resulted in an antibiotic prescription, and 89% were inappropriate. Antibiotics were prescribed more frequently in non-PWH (35% PWH vs 40% non-PWH; P = .172) and managed according to guidelines more often in PWH (37% PWH vs 30% non-PWH; P = .039). Antibiotics were prescribed appropriately most frequently in PWH managed by HIV clinicians (29% PWH managed by HIV clinician vs 12% PWH managed by non-HIV clinician vs 8% non-PWH; P = .010). HIV clinicians prescribed antibiotics for a mean duration of 5.9 days vs PWH managed by a non-HIV clinician for 9.1 days vs non-PWH for 7.6 days (P Conclusions Outpatient antibiotic overuse remains prevalent among patients evaluated for ARI. We found less frequent inappropriate antibiotic use in PWH. Prescriber specialty, rather than HIV diagnosis, was related to appropriateness of antimicrobial prescribing.

Despite the use of platinum-based chemotherapy, lung cancer continues to be the leading cause of cancer related death in the world. To overcome the rate of lung cancer related death, scientists discovered advanced therapies including mutant Epidermal Growth Factor Receptor-tyrosine kinase (EGFR-TK) inhibitors. Included in this study are nine phase 3 randomized controlled trials designed to study the safety profile of mutant EGFR-TK inhibitors in patients with advanced non-small cell lung cancer. The study showed that mutant EGFR-TK inhibitors have an incidence of adverse effects that is far less than platinum-based chemotherapy. Adverse effects reported were tolerable and easily manageable by slowing the infusion rate, decreasing the dosage, and skipping a dosage in symptomatic patients.

With an increase in number of cases of relapsed or refractory multiple myeloma (RRMM), scientist have discovered various combination of medications among which one is daratumumab, Daratumumab is a mono-clonal antibody which attacks CD-38 markers present in abundance on the surface of myeloma cells and is used universally for the treatment of primary newly diagnosed multiple myeloma patients.This meta-analysis was conducted according to Cochrane Collaboration guidelines in which initially 679 articles were evaluated for relevance on abstract level followed by full text screening of final list of 45 articles. Out of the 45 articles, only 10 articles qualified for selection criteria for eligibility. Three Phase 3 randomized control clinical trials which includes primary outcomes of progression free span and secondary outcomes including complete response, partial response or very good partial response and adverse effects reported were included in this study.A total of three studies including 1533 patients (849 in Daratumumab treatment group while 684 patients in control group) were included in the study. All three of these studies were phase 3 clinical trial conducted to observe the role of daratumumab in relapsed and refractory multiple myeloma. Mean age reported was 65 years in both treatment and control groups. This study showed that daratumumab improves primary and secondary outcomes including progression free span, overall response rate, very good partial response, and complete response. However, daratumumab increases drug induced adverse effects.Our study confirmed that daratumumab in combination therapy improved primary and secondary outcomes when compared with platinum-based chemotherapy, but more adverse effects were reported in the combination group. So, we recommend that combination therapy should include daratumumab in treatment of relapsed and refractory multiple myeloma patients.

In the Intensive Care Unit of hospitals, the biggest dilemma of choice is knowing when to withhold and when to withdraw potentially life supporting system where majority ofthe death cases are preceded. Bio-ethics, in this niche provide ambiguous advice. That’s because the focus is more on the moral value of withholding or withdrawing the support system, instead of focusing more on the awareness, intervention options and how interpersonal values are discussed and enacted. It is imperative to seek patient’s consent before proceeding, but in critical situation it becomes difficult to abide by obligations to secure consent. This research paper encompasses the question about how the choice of withholding and withdrawing faces different ethical concerns, both with positive and negative interpretations and how this situation has highlighted futility in the ICU.

Introduction: Diabetes is one of the main problems in health systems in the world.The world prevalence of diabetes among adults was 6.4%, and will increase to 7.7% by 2030. Patients with diabetes are at greater risk of complications, the most important of them are diabetic neuropathy and peripheral vascular disordersthat lead to diabetic foot ulcers. Objectives of the study: The basic aim of the study is to examine the risk of foot ulcers in patients with diabetes mellitusin local population of Pakistan. Methodology of the study: This descriptive study was conducted at Services institute of medical sciences, Lahore during Dec 2017 to March 2018. In this descriptive analytical study all patients with diabetes under 65 years referred to the hospital were studied. Exclusion criteria of the study were hypothyroidism, pernicious anemia, discopathy, malignancy because they can also lead to neuropathy. Results: Fifty patients with foot ulcers were treated at the hospital during this period. Forty controls attending the same diabetic clinic during the same period were also selected for the analysis. The mean age of the total sample was 55.5 years. The majority of the sample was male (51.1%), non-smokers (95.6%) and did not have hypertension (67.8%). The average duration after diagnosis of diabetes mellitus was 6.1 years. Conclusion: It is concluded that it is difficult to treat the foot ulcer in diabetic patients. It can be difficult to differentiate local soft tissue infection and inflammation from osteomyelitis. Three-phase bone scans and radiolabelled leukocyte scans are expensive but can help to establish an accurate diagnosis in problematic cases.&nbsp

Introduction: The liver is the largest organ of the body, weighing 1 to 1.5 kg and representing 1.5 to 2.5% of the lean body mass. Liver is a complex organ with interdependent metabolic, excretory and defense functions. Objectives of the study: The basic aim of the study is to find the changes in the serum liver enzymes in those patients who is suffering from liver cirrhosis. Material and methods: This study was conducted at hospitals of Gujranwala and Nawaz Sharif medical college Gujrat during June 2018 to July 2018. This study was done with the permission of ethical comittie of hospitals. Present study was comprised of total 60 subjects both male and female. In this research analysis we divided the subject’s into groups. One is control group which consist of 15 Healthy control and 45 case group aged between 30 -50 years, each case group consisted of 15 male patients of similar age suffering with Viral Hepatitis, Alcoholic Liver disease (more than 10 yrs) and liver cirrhosis. Results: The results indicated that the level of all liver enzymes become increases in all types of liver issues. Alanine aminotransferase levels were significantly raised in viral hepatitis, alcoholic liver disease and cirrhosis patients. The levels being 258.2±91.73, 79.66±28.63, and 50.73± 8.4 respectively as compared to normal control (11±3.42). Conclusion: It is concluded that the level of all liver enzymes become increases in cirrhosis condition. Liver associated enzymes tests are used to detect, specifically diagnose, and estimate the severity of hepatic disease.

Importance On the basis of observational studies, the use of thiazide diuretics for the treatment of hypertension is associated with reduced fracture risk compared with nonuse. Data from randomized clinical trials are lacking. Objective To examine whether the use of thiazide diuretics for the treatment of hypertension is associated with reduced fracture risk compared with nonuse. Design, Setting, and Participants Using Veterans Affairs and Medicare claims data, this study examined hip and pelvic fracture hospitalizations in Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial participants randomized to first-step therapy with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), or an angiotensin-converting enzyme inhibitor (lisinopril). Recruitment was from February 1994 to January 1998; in-trial follow-up ended in March 2002. The mean follow-up was 4.9 years. Posttrial follow-up was conducted through the end of 2006, using passive surveillance via national databases. For this secondary analysis, which used an intention-to-treat approach, data were analyzed from February 1, 1994, through December 31, 2006. Main Outcomes and Measures Hip and pelvic fracture hospitalizations. Results A total of 22 180 participants (mean [SD] age, 70.4 [6.7] years; 43.0% female; and 49.9% white non-Hispanic, 31.2% African American, and 19.1% other ethnic groups) were followed for up to 8 years (mean [SD], 4.9 [1.5] years) during masked therapy. After trial completion, 16 622 participants for whom claims data were available were followed for up to 5 additional years (mean [SD] total follow-up, 7.8 [3.1] years). During the trial, 338 fractures occurred. Participants randomized to receive chlorthalidone vs amlodipine or lisinopril had a lower risk of fracture on adjusted analyses (hazards ratio [HR], 0.79; 95% CI, 0.63-0.98;P = .04). Risk of fracture was significantly lower in participants randomized to receive chlorthalidone vs lisinopril (HR, 0.75; 95% CI, 0.58-0.98;P = .04) but not significantly different compared with those randomized to receive amlodipine (HR, 0.82; 95% CI, 0.63-1.08;P = .17). During the entire trial and posttrial period of follow-up, the cumulative incidence of fractures was nonsignificantly lower in participants randomized to receive chlorthalidone vs lisinopril or amlodipine (HR, 0.87; 95% CI, 0.74-1.03;P = .10) and vs each medication separately. In sensitivity analyses, when 1 year after randomization was used as the baseline (to allow for the effects of medications on bone to take effect), similar results were obtained for in-trial and in-trial plus posttrial follow-up. Conclusions and Relevance These findings from a large randomized clinical trial provide evidence of a beneficial effect of thiazide-type diuretic therapy in reducing hip and pelvic fracture risk compared with treatment with other antihypertensive medications. Trial Registration clinicaltrials.gov Identifier:NCT00000542

Background HIV infection in pregnant females confers a higher risk of morbidity and obstetric complications. Widespread use of anti-retroviral therapy (ART) has dramatically decreased vertical HIV transmission. US HIV-infected pregnant females continue to be at higher risk for obstetric complications compared with nonHIV infected females. This study will be conducted with the objective to estimate the current US morbidity and mortality in HIV-infected pregnant females as well as incidence of obstetric complications in this patient population. Methods The National Inpatient Sample (NIS) was utilized to identify hospitalizations associated with pregnancy from 2002 to 2014. The aggregation of hospitalizations was stratified into 2 groups based on HIV status to determine whether there were differences in demographic factors, complications, and mortality. All analyses accounted for the NIS sampling design. Results There were 39,404,956 pregnancy-related hospitalizations identified; of which, 51,762 were also associated with a positive HIV status. There were differences in complications for those with and without HIV, which included eclampsia (1.27% vs. 0.45%; P < 0.001), preterm labor (11.81% vs. 6.41%; P < 0.001), gestational diabetes (0.92% vs. 0.38%; P < 0.001), group B strep (0.03% vs. Conclusion As ART are readily available, we expected better outcomes for our HIV-positive pregnant females. Our results are concerning that there is such an increase rate of mortality and health disparity in HIV-positive pregnant females. As this is a retrospective study, there are limitation and further studies need to be conducted. Disclosures All authors: No reported disclosures.

Background As the pipeline for antibiotics is decreasing and antibiotic resistance is increasing, it is critically important to be stewards of antibiotics. ASP has become a mandated program as of January of 2017 by Joint Commission and condition of participation for CMS on reimbursement. A pilot program of C. difficile treatment in the academic medical center proved to be quite useful to adapt to a larger healthcare system. Methods A dedicated Infectious Disease physician and three Antibiotics stewardship pharmacists (ASP) were hired to run this program. Goals of the program was to decrease broad-spectrum antibiotics use, and reduce Clostridium difficile readmission (CDR) for the healthcare system. Performance of CDR for each inpatient was accomplished with ASP making recommendations for treatment. Queries were built into the ASP software and alerts were generated in the electronic medical record (EMR). CDR was targeted daily for ASP pharmacists/ID physician. Comparison of fiscal year 2017 (control group) with 2018 (intervention group) was performed. Results CDR was reduced (control group 17.53% vs. intervention group 14.12%), respectively, for our healthcare system (P > 0.05). However, overall cost savings for the healthcare system was $1.3 million was realized. In the academic medical center specifically, with over 400 beds there was a significant reduction in CDR (control group 21% to intervention group 10.5% (P < 0.05). Cost savings estimated from CDR were $610,923. Finally, length of stay was reduced by 1 day for inpatients with C. difficile admission in the academic medical center. Conclusion ASP not only has immediate impact on patient care and safety but also can play a large role in treating the appropriate disease state and reduces unnecessary readmission to the acute care hospitals in our healthcare system. Disclosures All authors: No reported disclosures.

With the incorporation of targeted therapies in routine cancer therapy, it is imperative that the array of toxicities associated with these agents be well-recognized and managed, especially since these toxicities are distinct from those seen with conventional cytotoxic agents. This review will focus on these renal toxicities from commonly used targeted agents. This review discusses the mechanisms of these side effects and management strategies. Anti-vascular endothelial growth factor (VEGF) agents including the monoclonal antibody bevacizumab, aflibercept (VEGF trap), and anti-VEGF receptor (VEGFR) tyrosine kinase inhibitors (TKIs) all cause hypertension, whereas some of them result in proteinuria. Monoclonal antibodies against the human epidermal growth factor receptor (HER) family of receptors, such as cetuximab and panitumumab, cause electrolyte imbalances including hypomagnesemia and hypokalemia due to the direct nephrotoxic effect of the drug on renal tubules. Cetuximab may also result in renal tubular acidosis. The TKIs, imatinib and dasatinib, can result in acute or chronic renal failure. Rituximab, an anti-CD20 monoclonal antibody, can cause acute renal failure following initiation of therapy because of the onset of acute tumor lysis syndrome. Everolimus, a mammalian target of rapamycin (mTOR) inhibitor, can result in proteinuria. Discerning the renal adverse effects resulting from these agents is essential for safe treatment strategies, particularly in those with pre-existing renal disease.

A 37-year-old man presented with worsening headache, vomiting, and right-sided weakness over the last few weeks. A head computed tomography showed a left hemispheric posterior medial parietal lobe lesion with surrounding edema. Further imaging with magnetic resonance imaging showed multiple enhancing mass lesions. The largest lesion measured 2.4 cm within the left occipital parietal region (Figure A and B). Laboratory data showed reactive HIV antibodies, confirmed by Western blot. An absolute CD4 count was 22 cells/μL. Other laboratory test results showed low sodium, thyrotropin, FT4, FT3, cortisol levels, corticotropin, luteinizing hormone, and testosterone. Based on these findings, the brain lesions were believed to be causing his panhypopituitarism. A brain biopsy confirmed the presence of Toxoplasma gondii by polymerase chain reaction. The patient was started on pyrimethamine and clindamycin for toxoplasmosis treatment, and azithromycin and sulfamethoxazole/trimethoprime for appropriate prophylaxis. He was also started on hormone supplementation. His symptoms were completely resolved at the time of discharge.