Unusual foreign bodies visualized by postmortem computed tomography in a deceased with borderline personality disorder

The objective of this case report is the visualization and assessment of ingested or inserted foreign bodies by postmortem computed tomography and autopsy. The presence of foreign objects in the gastrointestinal tract involves, among many other medical subdisciplines, the fields of forensic medicine and psychiatry. We present a case of an 18-year-old female Caucasian with borderline personality disorder who was found unconscious in a closed psychiatric ward with suspected ingested foreign bodies. Cardiopulmonary resuscitation was unsuccessful. Postmortem computed tomography revealed several sharp foreign bodies in the intestine varying in radiodensity and shape but not perforating any anatomic structures. The autopsy showed well-preserved tablets in the intestine, a few inserted glass fragments and one metal fragment. Ultimately, fatal intoxication involving a mixture of opioids, benzodiazepines, neuroleptics and antidepressants resulted. This case illustrates the potential contribution of postmortem computed tomography in diagnosing, localizing and defining ingested and inserted foreign bodies in deceased as well as living individuals. Thus, diagnostic imaging might increase safety not only for the affected individuals but also for medical staff.

Clarifying prognostic factors of small cell osteosarcoma: A pooled analysis of 20 cases and the literature

Introduction

Small cell osteosarcoma (SCOS) is a rare subtype of osteosarcoma, with limited studies mainly focusing on histological features. Our study aims to analyze our own patients and those reported in the literature to increase the recognition of this rare disease, to evaluate patient survival and to further determine potential prognostic factors.

Material and methods

Twenty patients with SCOS were treated in our hospital between 2010 and 2019. Their follow-up data were collected retrospectively. A total of 336 literature cases from 58 manuscripts were retrieved by means of a PubMed search with the key word “small cell osteosarcoma”. Data pertaining to treatment and follow-up were extracted. We performed a pooled analysis for the survival of patients and the risk factors for local recurrence (LR), as well as metastatic disease (MD), in a total of 160 patients using the Kaplan-Meier method and Cox regression method.

Results

We reported our experience in diagnosing and treating SCOS. In our cases, elevated alkaline phosphatase (P = 0.013) and lactate dehydrogenase (P = 0.001) significantly impaired overall survival. In the pooled analysis, SCOS was diagnosed at the median age of 17 years and affected both sexes almost equally. The median follow-up duration was 19.5 months. In the pooled analysis cases, the 5-year overall survival rate was 38.6%, and 36.4% of patients survived 10 years. However, an increasing trend was detected, indicating recent improvements in management. The surgical margin status (P = 0.024) and metastases (P = 0.008) significantly impaired overall survival, and the response to chemotherapy was related to disease-free survival (P = 0.012). LR and MD were significantly correlated (P = 0.002) and could be observed after 5 years of follow-up. LR was significantly dependent on response to chemotherapy (P = 0.020). The development of MD seemed to be affected by response to chemotherapy (P = 0.060). Correlations between imaging features and prognosis were not detected.

Conclusions

This study suggested that positive margins, poor response to chemotherapy and MD are negative prognostic factors for SCOS, implied the potential role of laboratory examinations in the survival prediction and supported the need for prolonged or more intensive surveillance in patients with MD or LR. More well-documented literatures are encouraged to allow further confirmations.

Bone histomorphometric and immunohistological analysis for hyperostosis in a patient with SAPHO syndrome: A case report

A 56-year-old Japanese woman with a history of palmoplantar pustulosis was admitted for examination due to left femur pain. Radiography and computed tomography showed thickening of the bone on the outer portion of the left femur. Bone scintigraphy of the left femur showed intense radioactive uptake. Consequently, the patient was diagnosed with SAPHO syndrome. Bone histomorphometric analysis of the left femur showed cancellous bone with thickened cortical bone. Whilst normal bone shows cancellous bone with double labeling (normal turn over), and cortical bone with no labeling (low turn over, adynamic state), this case presented with both cancellous and cortical bone with marked double labeling (indicating high turn over), abundant osteoid and woven bone. Immunohistological analysis showed that cells lining the bone surface consisted of osteoblasts and were positive for alkaline phosphatase (ALP). Few to little of these cells were positive for tartrate-resistant acid phosphatase (TRAP)-5B, cathepsin K and matrix metallopeptidase 9 (MMP-9). These results indicate that, in this case study, excessive production of osteoblasts contributed to hyperostosis of the left femur, with abundant osteoid and woven bone. This type of bone formation in SAPHO syndrome is not lamellar bone seen in normal bone, but rather fragile and mechanically weak bone, resulting in bone pain. Doxycycline may be a therapeutic option for bone pain in this patient.

Cervical Dystonia Caused by Chronic Nonunion C2 Fracture: A Case Report

Chronic nonunion cervical fracture leading to cervical dystonia (CD) is very rare. This study reports a 72-year-old man who presented with 9-month history of progressively worsening neck tilting, neck tightness, neck pain, headache, and difficulty with swallowing. The patient was referred to speech therapy and confirmed to have dysphagia on modified barium swallow study. A cervical spine radiograph showed a chronic C2 nonunion fracture. Subsequent cervical spine magnetic resonance imaging confirmed chronic C2 nonunion fracture with kyphotic deformity of the cervical canal with associated cord compression at C1-C2 and severe central canal stenosis. Needle electromyography revealed dystonic or spasmodic neck muscles, consistent with diagnosis of CD. Botulinum toxin injection resulted in marked clinical improvement. The patient finally underwent occipital to C4 posterior segmental fusion. No recurrence of CD had occurred 12 months after botulinum toxin injection and surgery, which supports the conclusion that chronic C2 nonunion fracture is most likely responsible for CD in this case. The authors suggest that all patients with CD receive dysphagia evaluation and more importantly cervical spine imaging to rule out chronic C2 nonunion fracture.

Aortic Rupture as a Complication of Cardiopulmonary Resuscitation

A 78-year-old woman with an aortic pseudoaneurysm suffered cardiac arrest due to aspiration and underwent cardiopulmonary resuscitation (CPR), but was found to then be hypotensive with a new chest hematoma. Imaging revealed aortic rupture at the site of the pseudoaneurysm. Aortic rupture is a rare but catastrophic complication of CPR. (Level of Difficulty: Beginner.).

Pseudo-Acute Myocardial Infarction in a Young COVID-19 Patient

A 29-year-old man tested positive for COVID-19 and developed acute respiratory distress syndrome. While mechanically ventilated, his electrocardiogram showed inferior ST-segment elevations, with normal serial cardiac troponin I and transthoracic echocardiograms. He was treated conservatively, with complete clinical recovery and resolution of his electrocardiographic abnormalities. (Level of Difficulty: Beginner.).

Giant Right Coronary Artery Aneurysm: An Association With Primary Varicose Veins?

Coronary artery aneurysms are rare conditions with potentially devastating consequences. We describe the case of an athletic 40-year-old woman who received a diagnosis of giant right coronary artery aneurysm while she was undergoing a work-up for lower extremity varicose veins. She underwent successful surgical treatment without any complications. (Level of Difficulty: Intermediate.).

Delayed cerebral ischemia causing cortical blindness due to repeat cocaine use weeks subsequent to aneurysmal subarachnoid hemorrhage

Cocaine is a known vasoactive drug associated with poor clinical outcomes and high in-hospital mortality related to aneurysmal subarachnoid hemorrhage; however, the association of prior cocaine use with the incidence of vasospasm and delayed cerebral ischemia remains controversial. We report a case of a 42-year-old male with a history of active cocaine use who presented with a severe headache. Imaging demonstrated diffuse cisternal subarachnoid hemorrhage due to a ruptured basilar apex aneurysm, which was successfully treated with endovascular coil embolization. Despite expedited endovascular treatment and an initially benign clinical course, he suffered from delayed cerebral ischemia resulting in cortical blindness due to bilateral posterior cerebral artery vasospasm secondary to repeat cocaine use weeks after his initial ictus. To our knowledge, the present case is the first to describe delayed cerebral ischemia resulting in a severe neurologic deficit due to repeat cocaine use weeks subsequent to aneurysm rupture. We review the current literature on the association of cocaine use with the incidence of vasospasm and delayed cerebral ischemia as well as the effects of cocaine on the cerebrovasculature.

Subacute Left Ventricular Free Wall Rupture after Delayed STEMI Presentation During the COVID-19 Pandemic

The coronavirus disease-2019 (COVID-19) pandemic is causing delayed ST-segment elevation myocardial infarction (STEMI) presentations associated with now unusual postinfarction complications. We describe a delayed (5-day) STEMI presentation because the patient feared contracting COVID-19 in the hospital. The patient experienced an extensive anterolateral STEMI complicated by subacute left ventricular free wall rupture that required a rapid surgical repair. (Level of Difficulty: Intermediate.)

Added value of invasive needle techniques in mediastinal and hilar nodal staging of clinical N0-N1 non-small cell lung cancer after positron emission tomography

Previous studies evaluating staging methods of lung cancer have focused on mediastinal disease. We explored the added value of endoscopic techniques after PET scan in the evaluation of N1 nodal stations in 276 patients with a radiologically normal mediastinum demonstrating a potential stage shift in 20% of patients.

Rapid Prototyping Flexible Aortic Models Aids Sizing of Valve Leaflets and Planning the Ozaki Repair

Two patients with bicuspid aortic valve were selected for aortic valve repair using the Ozaki procedure. Patient-specific models of their aortic roots were generated based on computed tomography data and were 3-dimensional printed using a flexible resin. The models allowed sizing of the valve leaflets and practicing of leaflet suturing. (Level of Difficulty: Advanced.).

Radiotherapy for the treatment of pituitary adenomas: A dosimetric comparison of three planning techniques

AIM

Our goal was to compare conformal 3D (C3D) radiotherapy (RT), modulated intensity RT (IMRT), and volumetric modulated arc therapy (VMAT) planning techniques in treating pituitary adenomas.

BACKGROUND

RT is important for managing pituitary adenomas. Treatment planning advances allow for higher radiation dosing with less risk of affecting organs at risk (OAR).

MATERIALS AND METHODS

We conducted a 5-year retrospective review of patients with pituitary adenoma treated with external beam radiation therapy (C3D with flattening filter, flattening filter-free [FFF], IMRT, and VMAT). We compared dose-volume histogram data. For OARs, we recorded D2%, maximum, and mean doses. For planning target volume (PTV), we registered V95%, V107%, D95%, D98%, D50%, D2%, minimum dose, conformity index (CI), and homogeneity index (HI).

RESULTS

Fifty-eight patients with pituitary adenoma were included. Target-volume coverage was acceptable for all techniques. The HI values were 0.06, IMRT; 0.07, VMAT; 0.08, C3D; and 0.09, C3D FFF (p < 0.0001). VMAT and IMRT provided the best target volume conformity (CI, 0.64 and 0.74, respectively; p < 0.0001). VMAT yielded the lowest doses to the optic pathway, lens, and cochlea. The position of the neck in extreme flexion showed that it helps in planning mainly with VMAT by allowing only one arc to be used and achieving the desired conformity, decreasing the treatment time, while allowing greater protection to the organs of risk using C3D, C3DFFF.

CONCLUSIONS

Our results confirmed that EBRT in pituitary adenomas using IMRT, VMAT, C3D, C3FFF provide adequate coverage to the target. VMAT with a single arc or incomplete arc had a better compliance with desired dosimetric goals, such as target coverage and normal structures dose constraints, as well as shorter treatment time. Neck extreme flexion may have benefits in treatment planning for better preservation of organs at risk. C3D with extreme neck flexion is an appropriate treatment option when other treatment techniques are not available.

Predictors, Presentation, and Treatment Outcomes of Recurrent Hepatocellular Carcinoma After Liver Transplantation: A Large Single Center Experience

BACKGROUND

Liver transplantation (LT) is an accepted therapeutic option for hepatocellular carcinoma (HCC) in patients with cirrhosis. Despite careful candidate selection, HCC recurrence occurs. We aimed to describe the predictors of recurrence, clinical presentation, and predictors of survival after HCC recurrence post-LT.

METHODS

Patients with recurrent HCC after LT between January 1996 and December 2017 were retrospectively reviewed.

RESULTS

Of 711 patients, 96 (13.5%) patients had post-LT HCC recurrence. The median time to recurrence was 17.1 months, and the median survival was 10.1 months. Initial recurrence was more often in the graft (34.4%), and most (60.4%) had multiple recurrent lesions, and 26% were in multiple sites. In multivariate analysis, factors associated with shorter survival were poorly differentiated histology in explant (Hazard ratio [HR] = 1.96; p = 0.027), bilirubin ≥1.2 mg/dL (HR = 2.47; p = 0.025), and albumin <3.5 mg/dL (HR = 2.13; p = 0.014) at recurrence, alpha-fetoprotein at recurrence ≥ 1000 ng/mL (HR = 2.96; p = 0.005), and peritoneal disease (HR = 3.20; p = 0.022). There was an increased survival in patients exposed to sirolimus (HR = 0.32; p < 0.0001).

CONCLUSIONS

Recurrent HCC after LT is often in extrahepatic sites with a decreased survival in those with poorly differentiated explant pathology, high bilirubin, low albumin, marked elevation of alpha-fetoprotein at recurrence, and peritoneal recurrence. Sirolimus-based immunosuppression may provide benefit.

Chest CT findings of early and progressive phase COVID-19 infection from a US patient

The SARS-CoV-2 infection (COVID-19), originally reported in Wuhan, China, has rapidly proliferated throughout several continents and the first case in the United States was reported on January 19, 2020. According to the ACR guidelines issued shortly after this disease was declared a pandemic, radiologists are expected to familiarize themselves with the CT appearance of COVID-19 infection in order to be able to identify specific findings of this entity. This case report discusses the relevant imaging findings of one of the first cases in the mid-western United States. It involves a 60-year-old man who presented with fever, dyspnea, and cough for 1 week and subsequently tested positive for COVID-19. The utility of the noncontrast CT chest in the diagnosis of COVID-19 has been controversial, but there are specific imaging findings that have been increasingly associated with this virus in the appropriate clinical context. The stages of imaging findings in COVID-19 are considered along with the implications of fibrosis throughout the stages. Future considerations include using artificial intelligence algorithms to distinguish between community acquired pneumonias and COVID-19 infection.

Thoracoabdominal aneurysmectomy: Operative steps for Crawford extent II repair

Background

Open surgical repair remains the gold standard for treatment of thoracoabdominal aortic aneurysm (TAAA). Surgery aims to replace the whole length of the diseased distal aorta while protecting the spinal cord and the visceral organs to limit ischemia-related complications. The substantial associated surgical risks, including death, paraplegia, renal failure requiring permanent dialysis, and respiratory complications leading to prolonged intensive care unit stay, still outweigh the natural history of TAAA with conservative treatment.

Methods

We describe in detail our current approach to open extent II TAAA repair with a step-by-step illustration of the technique and the surgical adjuncts.

Results

We routinely perform left heart bypass with mild passive hypothermia (34°C), cerebrospinal fluid drainage, sequential aortic cross-clamping, monitoring of motor evoked potentials (MEPs) and cerebral, paraspinal, and lower limb oxygen saturation by near-infrared spectrometry, as well as selective visceral perfusion via the celiac and superior mesenteric arteries and renal protection with intermittent administration of Custodiol HTK (histidine-tryptophan-ketoglutarate) solution via the renal arteries. We advocate for individual branch reimplantation using a branched thoracoabdominal graft when possible, and we selectively reattach 1 or more pairs of the lower thoracic intercostal arteries and/or high lumbar arteries, even in the absence of a significant reduction in the MEPs signal. The distal anastomosis is usually constructed above the aortic bifurcation and occasionally to each iliac separately using a bifurcated graft.

Conclusions

Favorable early outcomes and a durable TAAA repair can be achieved at experienced high-volume centers with standardized preoperative selection and multidisciplinary team-based intraoperative and postoperative management of these patients.

Features of resistance-associated substitutions after failure of multiple direct-acting antiviral regimens for hepatitis C

Background & Aims

We aimed to clarify the features of resistance-associated substitutions (RASs) after failure of multiple interferon (IFN)-free regimens in HCV genotype 1b infections.

Methods

A total of 1,193 patients with HCV for whom direct-acting antiviral (DAA) treatment had failed were enrolled from 67 institutions in Japan. The RASs in non-structural protein (NS)3, NS5A, and NS5B were determined by population sequencing.

Results

Failure of 1, 2, and 3 regimens was observed in 1,101; 80; and 12 patients, respectively. Among patients with failure of 1 regimen, Y56H and D168V in NS3 were more frequently detected after failure of paritaprevir, whereas D168E was more frequently detected after failure of regimens including asunaprevir. R30H and L31-RAS in NS5A were frequently detected after failure of regimens including daclatasvir. The prevalence of Y93-RAS was high irrespective of the regimen. S282T RAS in NS5B was detected in 3.9% of ledipasvir/sofosbuvir failures. The prevalence of D168-RAS increased significantly according to the number of failed regimens (p <0.01), which was similar to that seen with L31-RAS and Y93-RAS. The prevalence of patients with RASs in either NS3 or NS5A, or in both, increased significantly with increasing numbers of failed regimens. The P32del, which is unique to patients for whom DAA had failed, was linked to the absence of Y93H, the presence of L31F, and previous exposure to IFN plus protease inhibitor regimens.

Conclusions

Failure of multiple DAA regimens can lead to the generation of multiple RASs in the NS3 and NS5A regions of the HCV 1b genome. These mutations contribute to viral resistance to multiple treatment regimens and, therefore, should be considered during decision making for treatment of chronic HCV.

Lay summary

Resistance-associated substitutions (RAS) in the genome of the hepatitis C virus are 1 of the major causes for failed treatment. We investigated RASs after failure of various treatments for chronic hepatitis C, and found that more complicated RASs accumulated in the viral genome with successive failed treatments. The highly resistant P32del RAS at NS5A region was uniquely found in patients for whom DAA treatments had failed, and was linked to the presence and absence of specific RASs.

Catheter-Directed Mechanical Thrombectomy in Massive Pulmonary Embolism With Cardiogenic Shock

We discuss a patient who presented with cardiogenic shock secondary to massive pulmonary embolism and right ventricular failure. She was managed by a multidisciplinary heart team and treated with catheter-directed thrombectomy, followed by ProtekDuo (Tandem [Liva Nova], London, United Kingdom) heart percutaneous right ventricular support leading to complete recovery from this often fatal condition. (Level of Difficulty: Intermediate.)

Adverse Events and Mortality in Anticoagulated Patients with Different Categories of Pulmonary Embolism

Objective

To determine whether the pulmonary embolism (PE) categories of massive, submassive, PE with no right ventricle dysfunction (NRVD), and subsegmental only (SSO) adequately predict clinical outcome.

Methods

Patients treated for acute PE (March 1, 2013, through July 31, 2019) were followed forward prospectively to compare venous thromboembolism (VTE) recurrence, all-cause mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) across 4 PE categories.

Results

Of 2703 patients with VTE, 1188 (44%) had PE, of which 1021 (85.9%) completed at least 3 months of therapy or had clinical outcomes precluding further treatment (27 with massive, 217 submassive, 557 NRVD, and 220 SSO PE). One patient with massive, 8 with submassive, 23 with NRVD, and 5 with SSO PE had recurrent VTE (3.90, 5.33, 5.36, and 3.66 per 100 person-years, respectively; P=.84). There were 3 deaths in massive, 27 in submassive, 140 in NRVD, and 34 in SSO PE groups (11.59, 17.37, 31.74, and 24.74 per 100 person-years, respectively; P=.02); when adjusted for cancer, the relationship was no longer significant (P=.27). One patient with massive, 5 with submassive, 22 with NRVD, and 5 with SSO PE had major bleeding (3.90, 3.31, 5.24, and 3.75 per 100 person-years, respectively; P=.66). Similar cumulative rates for CRNMB were observed (P=.87). Three-month rates of VTE recurrence, death, major bleeding, and CRNMB did not differ by PE category.

Conclusion

In the setting of anticoagulation therapy with maximal standardization and evidence-based practice, there is no evidence of a difference between PE categories and outcomes.

Trial Registration

clinicaltrials.gov Identifier: NCT03504007.

Constrictive Pericarditis After Lung Transplantation

As a rare complication after lung transplant, cardiac constriction should not be missed. Physical exam, echocardiography, and catheterization are essential for diagnosis A 65-year-old man with previous coronary artery disease and idiopathic pulmonary fibrosis underwent bilateral lung transplant and subsequently presented for progressive dyspnea and volume overload. Cardiac imaging and cardiac catheterization confirmed constriction, and complete pericardiectomy was performed. The patient had rapid resolution of heart failure symptoms. Pericardial constriction is a rare complication following lung transplant, and we provide a review of the literature and discussion of potential contributing factors. (Level of Difficulty: Intermediate.)

Cardiac Tumors: JACC CardioOncology State-of-the-Art Review

Cardiac masses are rare, but remain an important component of cardio-oncology practice. These include benign tumors, malignant tumors (primary and secondary) and tumor-like conditions (e.g., thrombus, Lambl’s excrescences, and pericardial cyst). The advent of multimodality imaging has enabled identification of the etiology of cardiac masses in many cases, especially in conjunction with information from clinical settings. This paper provides a comprehensive review of the epidemiology, clinical presentation, imaging, diagnosis, management, and outcomes of cardiac masses.

•

Cardiac tumors are rare and should be considered as part of the differential diagnosis of any space-occupying mass noted on cardiovascular and/or thoracic imaging modalities.

•

It may be possible to get close to a diagnosis without biopsy using a structured imaging approach.

•

The prognosis and treatment of each tumor is different, although early diagnosis is usually associated with a better outcome.

Acute Cor Pulmonale in COVID-19-Related ARDS: Improvement With Almitrine Infusion

Coronavirus disease-19 (COVID-19)-related severe acute respiratory distress syndrome can lead to acute cor pulmonale. We report a case of acute cor pulmonale secondary to severe COVID-19 acute respiratory distress syndrome diagnosed with transesophageal echocardiography. Almitrine infusion allowed rapid enhancement of right ventricular function as well as improvement in oxygenation. (Level of Difficulty: Intermediate.)

Urethroscrotal fistula complicating large spermatocele in a male ketamine abuser: A case report

Ketamine related urinary tract complications were first reported in Hong Kong since 2007. The current case report describes a 37 years old male with long history of ketamine abuse, renal impairment, hypertension and HCV hepatitis, presented to us with insidious onset of painful scrotal swelling post bilateral nephrectomy, prostate and seminal vesicle preserving cystectomy. Radiological imaging and intraoperative finding revealed that it was a large spermatocele with urethroscrotal fistula, which was likely due to urethra stricture. The review of literature showed no guidelines for treatment, a symptoms based and multidisciplinary team approach is recommended.

4 Cases of Aortic Thrombosis in Patients With COVID-19

Since the outbreak of the COVID-19 pandemic, increasing evidence suggests that infected patients present a high incidence of thrombotic complications. This report describes 4 cases of aortic thrombosis in patients admitted for COVID-19 infection between March 26 and April 12, 2020, in Mulhouse, France. (Level of Difficulty: Intermediate.)

Associations Among Self-reported Physical Activity, Coronary Artery Calcium Scores, and Mortality Risk in Older Adults

Objective

To assess whether self-reported physical activity during daily life reduces the mortality risk associated with atherosclerotic burden, as measured by coronary artery calcium (CAC) scanning.

Methods

We assessed 2318 patients aged 65 to 84 years who underwent CAC scanning from August 31, 1998, through November 16, 2016, and had daily life physical activity assessed by a single-item question that was used to divide patients by low, moderate, and high physical activity levels. Patients were followed for a mean ± SD of 10.6±4.9 years for the occurrence of all-cause mortality.

Results

The results indicated a graded relationship between the magnitude of CAC abnormality and mortality and an inverse relationship between physical activity and mortality. Of patients with low CAC scores (0-99), those with low, moderate, and high physical activity levels had similarly low mortality rates. Of patients with high CAC scores (≥400), however, there was a stepwise increase in mortality with decreasing physical activity. Patients with CAC scores of 400 or greater but reporting high physical activity had a mortality rate that was similar vs that observed in patients with CAC scores of only 0 to 99 and low physical activity (19.9 vs 16.3 per 1000 person-years; P=.60).

Conclusion

Combining CAC score with self-reported physical activity level provides a synergistic means for predicting clinical risk in older patients, with high physical activity level substantially attenuating the mortality risk associated with elevated CAC scores. Moreover, the useful prognostic information afforded by just a single-item physical activity questionnaire supports current initiatives to make such assessments into a "fifth vital sign."

Severe immune thrombocytopenia induced by nivolumab in a patient with metastatic renal cell carcinoma

In the Checkmate-025 trial, nivolumab treatment prolonged overall survival among patients with previously treated advanced renal cell carcinoma (RCC) compared with treatment with everolimus. Although effective, nivolumab is associated with immune-related adverse events (irAEs). However, the occurrence of hematological irAEs is rare. Some studies have reported on nivolumab-induced thrombocytopenia. Nivolumab associated thrombocytopenia in almost all patients improved with administration of various drugs. However, there have been only a few cases that have reported death owing to cancer aggravation. In this paper, we have described a case of nivolumab-induced thrombocytopenia after third-line treatment for metastatic RCC.