Successful systemic low-dose lysis of a caval thrombus by rt-PA in a neonate with congenital nephrotic syndrome

Late-Onset Hydroxyurea-Induced Melanonychia and Tongue Hyperpigmentation in a Patient With Polycythemia Vera: A Case Report

In a rare case, a 70-year-old female with polycythemia vera developed late-onset melanonychia, a seldom-documented side effect of hydroxyurea. Typically, melanonychia emerges within months of treatment, but this case is unique as it occurred four years into therapy. Notably, the patient, with darker skin, also had hyperpigmentation of her hands and tongue. Her history of hydroxyurea-associated ulcers and symptoms worsening with dose adjustment suggested drug involvement. While mucocutaneous hyperpigmentation from hydroxyurea is known, melanonychia and tongue hyperpigmentation are rarely reported, mostly in early treatment. This case highlights the importance of recognizing these side effects, especially in diverse populations and darker skin tones. The diverse skin tones seen in Sub-Saharan Africa add complexity to diagnosing such dermatological conditions, highlighting the need for awareness. Melanonychia can mimic severe conditions such as subungual melanoma, emphasizing the significance of accurate recognition and management without invasive tests. Educating clinicians and patients about these benign drug-related phenomena is essential for precise identification and management. This case contributes to understanding late-onset hydroxyurea-induced melanonychia and tongue hyperpigmentation, enhancing clinical knowledge in diverse populations.

Successful treatment of neonatal pulmonary thrombosis in congenital nephrotic syndrome

A 21-year-old adult patient with Tetralogy of Fallot presented acutely unwell with a 3-month history of general malaise following dental treatment. Following initial complete repair, he subsequently underwent two right ventricular outflow tract reconstructions with conduits. On admission, transthoracic echocardiography and peripheral blood cultures were suggestive of streptococcal endocarditis. Sequential computed tomography pulmonary angiography demonstrated peripheral emboli with progressive central pulmonary artery filling defects suggestive of thrombi and potential vegetations (Fig 1a and b). Urgent surgery was performed for uncontrolled sepsis and increasing hypoxia. Peri-operative transesophageal echocardiogram confirmed previous findings (Fig 1c; Supplementary Video 1). Having resected the conduit, we performed a peripheral pulmonary embolectomy and resected an abundance of the infected material from the pulmonary arterial tree under low-flow hypothermia; we then proceeded with a jugular venous valved conduit (Contegra®, Medtronic Inc, Minneapolis, Minnesota, United States of America) replacement and tricuspid valve annuloplasty. He made a slow but steady recovery and was discharged home in good health

Catheter-directed thrombolysis of inferior vena cava thrombosis in a 13-day-old neonate and review of literature

Complete inferior vena cava thrombosis (IVC) in neonates is uncommon, but may cause significant morbidity. A 13-day-old neonate suffered IVC thrombosis secondary to antithrombin III deficiency, possibly contributed to by a mutation in the methyl tetrahydrofolate reductase gene. Catheter-directed thrombolysis (CDT) with recombinant tissue plasminogen activator (rt-PA, Alteplase) was used successfully to treat extensive venous thrombosis in this neonate without complications. We also review the literature on CDT for treatment of IVC thrombosis in critically ill neonates and infants.

Safety and outcomes of thrombolysis with tissue plasminogen activator for treatment of intravascular thrombosis in children

OBJECTIVES

In this study, we tried to determine the safety and outcomes of thrombolysis with tissue plasminogen activator of intravascular thrombus.

STUDY DESIGN

Eighty consecutive children were treated between 1985 and 1999 in a tertiary care setting in a retrospective case series. There were 65 arterial thrombi (56 after cardiac catheterization) and 15 venous thrombi treated with tPA at an average dose of tPA of 0.5 mg/kg/hour for a median duration of 6 hours.

RESULTS

Clot resolution was complete in 65% of children, partial in 20%, and there was no effect in 15%. There were major complications in 40%, minor complications in 30%, and no complications in 30%. Two patients had cerebral ischemia secondary to hypotension because of profound bleeding, with intracranial hemorrhage in 2 additional patients. Clot resolution was not related to patient age or weight, dose, and duration of tPA therapy and fibrinogen levels. However, complications were more likely in patients who weighed less, had a longer duration of therapy, a greater decrease in fibrinogen levels, and who failed to have resolution of their clot.

CONCLUSIONS

tPA therapy can be effective in the thrombolysis of intravascular thrombus in children, but is associated with a low margin of safety and an unknown risk-benefit ratio.