Pembrolizumab, an immune checkpoint inhibitor targeting the programmed cell death 1 (PD-1) protein, is widely used for renal cell carcinoma but rarely causes central nervous system adverse events such as myelitis. A 58-year-old woman with stage IV renal clear cell carcinoma developed radiating hip pain, paresthesia, hypoesthesia (T10 and below), constipation, urinary retention, and sudden right-eye blurred vision one month after her sixth cycle of pembrolizumab and lenvatinib. Neurologic examination revealed asymmetrical inferior paraparesis, upper motor neuron signs, and right eye papilledema. MRI demonstrated patchy hyperintensity on C2-C6 and T2-T5, supportive of myelitis. Intravenous methylprednisolone was initiated, leading to pain relief and motor improvement. This is the first reported case of pembrolizumab-induced myelitis in Indonesia, emphasizing the importance of early recognition and corticosteroid therapy for optimal recovery.

We present a case of a critically ill patient with severe Legionella pneumonia complicated by morbid obesity (BMI ≥ 40 kg/m²) who was successfully treated with early initiation of veno-venous ECMO (V-V-ECMO) without any sequelae. The patient, a 48-year-old male, initially presented with symptoms of a sore throat, fever, significant fatigue, and decreased appetite. Upon diagnosis of severe pneumonia complicated by morbid obesity, he was transferred to our hospital for further management. Upon admission, he was promptly intubated and placed on mechanical ventilation. Due to a positive urinary Legionella antigen test indicating a risk of deterioration, V-V ECMO was initiated immediately after intubation. During ECMO support, the patient received Levofloxacin Hydrate at 500 mg/day and Prednisolone Sodium Succinate at 100 mg/day. He was successfully weaned off ECMO after 12 days and transferred back to the referring hospital on day 20. While ECMO therapy for morbidly obese patients was traditionally considered relatively contraindicated, this case suggest that obesity alone is not a contraindication to initiating ECMO.

Background: Propranolol is a non-cardio-selective beta-blocker, commonly used in patients with hyperthyroidism to treat the hyperadrenergic symptoms but also for its additional effect of blocking the peripheral conversion of inactive T4 to active T3. However, propranolol has many side effects, one of them being secondary Raynaud phenomenon. Case presentation: S.K., 55 years old was hospitalized in the Endocrinology Department as an untreated hyperfunctioning goiter with typical clinical manifestations such as fatigue, anxiety, palpitations, heat intolerance, difficulties in swallowing and breathing. Unimazole 5 mg (2-2-2 tb) and Propranolol 40 mg (¼ -0- ¼ tb) were prescribed. Thirty minutes after taking Propranolol (the dose 40 mg), she had difficulties breathing, was agitated, sweating and had nausea. Her face was hyperemic and edematous and her extremities were getting blue and cold. Her vitals remained stable and her airways were opened, as evaluated from laryngoscopy and CT-scan of the neck. 8 hours later, her clinical manifestations got worse: her facial edema spread in her lips and submandibular region. On both cases, she clinically improved after prednisolone administration. 12 hours after taking propranolol, she showed no more signs of cyanosis or edema. Propranolol was replaced by Nebivolol, with no side effects. Conclusion: Secondary Raynaud phenomenon is a common side effect of beta-blockers and should be taken in consideration in very patient presenting with cold and cyanotic peripherals. In these cases, propranolol should be stopped and replaced. Further studies on beta-blockers side effects in patients with hyperthyroidism should be made.