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Acharya S, Bhattarai S, Shrimanker I, Gupta SS. A prolonged paralysis with succinylcholine in pseudocholinesterase deficiency: an undesired effect. QJM 2022; 115:547-548. [PMID: 35426937 DOI: 10.1093/qjmed/hcac103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- S Acharya
- Department of Internal Medicine, Cayuga Medical Center, 101 Dates Drive, Ithaca, NY 14850, USA
| | - S Bhattarai
- Department of Internal Medicine, B & B Hospital Pvt Ltd, Gwarko, Lalitpur 44600, Nepal
| | - I Shrimanker
- Department of Internal Medicine, Cayuga Medical Center, 101 Dates Drive, Ithaca, NY 14850, USA
| | - S S Gupta
- Department of Pulmonary and Critical Care Medicine, Cayuga Medical Center, 101 Dates Drive, Ithaca, NY 14850, USA
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Asken MJ, Shrimanker I, Bhattarai S, Hortian V, Slaven V, Nookala V. Interns' anticipatory anxiety about cardiopulmonary resuscitation: reducing it while bolstering confidence with psychological skills training. Intern Emerg Med 2021; 16:2009-2011. [PMID: 34059999 DOI: 10.1007/s11739-021-02768-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/15/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Dealing with emergencies is a critical responsibility of physicians-in-training. Residents typically lead cardio-pulmonary resuscitation efforts in a teaching hospital. A 'Code Blue' is a situation that is highly challenging, time sensitive and very often highly anxiety-provoking. Recently, there is greater recognition of the need and value of integrating specific psychological performance skills training to better manage the stress of critical situations. In this study, we sought to evaluate the impact of including a psychological skills training program with BLS/ACLS training for performance and confidence optimization and mitigation of anxiety in 1 year residents related to participating in and leading emergency resuscitations. MATERIALS AND METHODS First-year residents across six specialties underwent traditional BLS/ACLS training with the addition of a 3 h psychological skills training component (Code Calm) as part of their residency orientation. Anxiety and confidence-based questionnaires were used to evaluate the residents' perceptions of code-related stress and confidence to lead resuscitation efforts. RESULTS Code-related anxiety scores demonstrated a statistically significant decrease post training (p < 0.0001); general confidence scores showed a statistically significant increase post-training (p < 0.001); confidence in leading resuscitation showed a statistically significant increase (p < 0.0001). DISCUSSION The results of this study demonstrate that BLS/ACLS training can positively influence anxiety and confidence in residents related to their resuscitation skills, especially if combined with psychological skills training. Future studies should evaluate the incremental value of including psychological skills training with BLS/ACLS and its impact on enhancing physical performance skills.
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Affiliation(s)
- Michael Joseph Asken
- Department of Graduate Medical Education, UPMC Harrisburg, 205 S. Front Street, Suite 902, Harrisburg, PA, 17104, USA.
| | - Isha Shrimanker
- Department of Internal Medicine, UPMC Pinnacle, Harrisburg, PA, USA
| | | | - Vanessa Hortian
- General Surgery Residency Program, UPMC Harrisburg, Harrisburg, PA, USA
| | | | - Vinod Nookala
- Department of Graduate Medical Education, UPMC Harrisburg, 205 S. Front Street, Suite 902, Harrisburg, PA, 17104, USA
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Lnu K, Khanal R, Shrimanker I, Nookala V, Theckumparampil N. SHOT THROUGH THE HEART : ANGINA LIKE SYMPTOMS DUE TO INFERIOR VENA CAVA FILTER FRACTURE MIGRATING TO INTERCOSTAL SPACE. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)03696-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Yarlagadda K, Sendil S, Tahir S, Hansrivijit P, Nookala V, Siddique Qurashi HM, Shrimanker I, Rao Vanjarapu JM, Patel P. CORRELATION BETWEEN RIGHT HEART CATHETERIZATION PRESSURES AND CLINICAL OUTCOMES IN PULMONARY HYPERTENSION. Chest 2020. [DOI: 10.1016/j.chest.2020.08.1425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kanderi T, Puthenpura M, Shrimanker I, Sapna F, Felter SC. Triple-Negative Essential Thrombocythemia Complicated by Thrombosis and Acquired von Willebrand Disease in a Young Man. Am J Case Rep 2020; 21:e924560. [PMID: 32829377 PMCID: PMC7478430 DOI: 10.12659/ajcr.924560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patient: Male, 25-year-old Final Diagnosis: Acquired von Willebrand deficiency Symptoms: Bleeding • chest discomfort Medication: — Clinical Procedure: Bleeding • chest discomfort Specialty: Laboratory Diagnostics • Hematology • General and Internal Medicine • Physiology
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Affiliation(s)
- Tejaswi Kanderi
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
| | - Max Puthenpura
- Department of Internal Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Isha Shrimanker
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
| | - Fnu Sapna
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
| | - Scott C. Felter
- Department of Hematology/Oncology, University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, Camp Hill, USA
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6
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Sendil S, Shrimanker I, Yarlagadda K, Bhandari B, Nookala VK. Takotsubo Cardiomyopathy in a Nonagenarian With Urosepsis. Cureus 2020; 12:e8763. [PMID: 32714701 PMCID: PMC7377657 DOI: 10.7759/cureus.8763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Takotsubo cardiomyopathy (TCM) is a rare but reversible myocardial left ventricular (LV) dysfunction, which mimics acute coronary syndrome (ACS) without the presence of significant coronary artery disease (CAD). Emotional stressors may include the death of kin or a life-threatening medical diagnosis whereas physical stressors include infections, endoscopic procedures, exacerbation of asthma, or systemic disorders. A 90-year-old female presented to the ED with nausea, intermittent chest heaviness, and generalized weakness for a duration of three days. Her troponin-I was elevated and an electrocardiogram (EKG) showed T-wave inversions in leads V2-V6 and no ST-segment changes. An echocardiogram (ECHO) revealed an ejection fraction (EF) of 35%-40% with anteroapical hypokinesis. She underwent cardiac catheterization showing nonobstructive CAD. She was diagnosed with pan-sensitive Escherichia coli urosepsis and started on ceftriaxone. She improved clinically and was discharged. A repeat ECHO done a month later showed normal EF. Urosepsis-induced TCM has rarely been reported in the literature. Physicians should have a high index of suspicion of TCM in patients with symptoms mimicking ACS in the presence of a physical stressor like an infection. We report the case of TCM, which resulted from a urinary tract infection (UTI) in an elderly female.
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Affiliation(s)
- Selin Sendil
- Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
| | - Isha Shrimanker
- Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
| | - Keerthi Yarlagadda
- Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
| | - Binita Bhandari
- Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
| | - Vinod K Nookala
- Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, USA
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Asken MJ, Goel S, Shrimanker I, Rizk MA, Abourizk N, Nookala V. Grit in Medical Education: Differing Perspectives of Residents and Mentors. Cureus 2020; 12:e8315. [PMID: 32607298 PMCID: PMC7320645 DOI: 10.7759/cureus.8315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Increasing concerns about depression and burnout in residents have led to a recent focus on assessing "non-cognitive" traits in residents and residency applicants. One attribute that has received significant attention is grit, defined as trait-level perseverance and passion for long-term goals. With an objective measure available, an important question is under what circumstances of administration is that measure reliable and accurate. The goal of this study was to ascertain whether internal medicine residents and their faculty mentors were congruent in their ratings of resident grit, or if not, how the ratings differed. Methods Subjects were internal medicine residents (N=42) at a community-based university-affiliated hospital internal medicine residency program. Near the end of the academic year 2019, residents completed the GRIT-S (short form). As each resident is assigned a mentor during their training, each resident's mentor was also asked to complete the GRIT-S based on their view of their mentee. Results This study failed to find a significant correlation between resident self-ratings of grit and those of their mentors. Conclusions The results of these two studies underscore the difficulty in obtaining accurate assessments of non-cognitive traits. These results further the understanding of the role of grit and raise important questions about how assessments might be used to assure validity. Further areas of inquiry into this potentially important characteristic are suggested.
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Affiliation(s)
- Michael J Asken
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Siddharth Goel
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Isha Shrimanker
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Michelle-Ashley Rizk
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Nicholas Abourizk
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Vinod Nookala
- Internal Medicine, Community Medical Center, Toms River, USA
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Abstract
Patient: Female, 70-year-old Final Diagnosis:Stenotrophomonas maltophilia Symptoms: Difficult to breath, patient could not wean from oxygen/premature Medication: — Clinical Procedure: — Specialty: General and Internal Medicine
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Affiliation(s)
- Tejaswi Kanderi
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, PA, USA
| | - Isha Shrimanker
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, PA, USA
| | - Qurat Mansoora
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, PA, USA
| | - Kajol Shah
- Department of Internal Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Anna Yumen
- Department of Internal Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Saketram Komanduri
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC) Pinnacle, Harrisburg, PA, USA
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Garg C, Shrimanker I, Goel S, Mclaughlin J, Nookala V. Extraintestinal Manifestations of Crohn’s Disease in the Form of Pulmonary Nodules: A Case Report. Cureus 2020; 12:e7161. [PMID: 32257704 PMCID: PMC7112714 DOI: 10.7759/cureus.7161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Crohn's disease is a systemic illness with a plethora of extraintestinal manifestations affecting various organs, of which the lungs are relatively rare. Pulmonary involvement may include airway diseases, lung parenchymal diseases, pleural diseases, or drug-related diseases. Tracheobronchial involvement is the most common respiratory presentation, whereas Crohn's disease-related interstitial lung disease is seen less frequently. A 41-year-old woman with a past medical history of Crohn's disease (status-post subtotal colectomy) presented to the hospital for an enlarging ground-glass opacity in her right middle lobe detected on routine computed tomography of the abdomen six months earlier. The opacity had increased in size from 21 x 18 mm to 28 x 18 mm and another ground-glass opacity in the right lower lobe increased in size from 5 mm to 12.4 mm. A robotic right middle lobectomy with lymph node dissection was done and bronchoscopy showed benign nodular lymphoid hyperplasia and a single perivascular epithelioid granuloma. A year later, her relapsing episodes of cough and shortness of breath were managed with prednisone, 20 mg, for a probable pulmonary manifestation of Crohn's disease. A non-contrast computed tomography of the chest showed interval resolution of the right lower lobe ground-glass opacity. A year after that, she presented to the hospital with increasing cough, shortness of breath, and a new right lower lobe ground-glass opacity (14 x 14 mm) on non-contrast computed tomography of the chest and has been managed with steroids with consideration of immunosuppression. In conclusion, pulmonary manifestations of Crohn's disease present in a myriad of varieties and often present confounding diagnostic problems necessitating an extensive work-up. Thus, Crohn's disease should be kept in the differential list in case of unusual clinical symptoms and radiological signs of idiopathic pulmonary presentations. These infrequent, and sometimes life-threatening, extraintestinal manifestations need to be considered when dealing with Crohn's disease to avoid further impairment of health status and alleviate patient symptoms by prompt recognition and treatment.
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Kanderi T, Goel S, Shrimanker I, Nookala VK, Singh P. Angioimmunoblastic T-cell Lymphoma: An Unusual Case in an Octogenarian. Cureus 2020; 12:e6956. [PMID: 32190506 PMCID: PMC7067515 DOI: 10.7759/cureus.6956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Angioimmunoblastic T-cell lymphoma (AITL) is an unusual subtype of mature peripheral T-cell lymphoma originating from the follicular T-helper cells and is often associated with autoimmune disorders. AITL is an aggressive lymphoma, presenting with constitutional symptoms, generalized lymphadenopathy, and hepatosplenomegaly. Immunohistochemistry and biopsy are diagnostic methods. The treatment modalities range from steroids, immunomodulators, and cytotoxic chemotherapy. An 87-year-old female presented to the emergency department with cough, dyspnea, dizziness, night sweats, and unintentional weight loss with multiple discrete swellings over her body for a duration of three days. Her physical exam was significant for tachycardia with dry mucous membranes and generalized lymphadenopathy. However, no hepatosplenomegaly was noted. Laboratory investigations revealed neutrophilic leukocytosis (12.8 K/uL), with elevated inflammatory markers (C-reactive protein of 1.39 mg/dL, sedimentation rate of 86 mm/hour). The biopsy of the cervical lymph node revealed atypical lymphoid infiltrates. Flow cytometry showed CD10+ and CD4+/CD8+ T-cells with a minority of CD23+ B-cells, and fluorescence in situ hybridization (FISH) reported gains of the BCL2 gene region on chromosome 18, all of which were suggestive of AITL. She was transferred to an advanced hematology center for staging and targeted therapy. A careful review of the patient with the prompt clinical and histological examination is essential for the correct diagnosis as the differentials are vast due to its non-specific clinical presentation and accurate treatment is a must for complete remission.
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Affiliation(s)
- Tejaswi Kanderi
- Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Siddharth Goel
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Isha Shrimanker
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Vinod K Nookala
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Pratiksha Singh
- Internal Medicine, Hackensack Meridian Health, Ocean Medical Center, Brick, USA
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Abstract
Conventionally, Lactobacillus species are considered as low virulence organisms and rarely cause infection in immunocompetent individuals. However, it might be an opportunistic infection source in immunocompromised patients and can cause invasive serious infections. To our knowledge, there are only a handful of cases in the literature reporting primary bloodstream infection caused by Lactobacilli spp. in transplant recipients. Here, we report a case of a kidney transplant recipient with Lactobacillus rhamnosus bacteremia.
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Affiliation(s)
- Selin Sendil
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Isha Shrimanker
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Qurat Mansoora
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - John Goldman
- Internal Medicine: Infectious Disease, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Vinod K Nookala
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
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Abstract
Hafnia alvei, belonging to the Enterobacteriaceae family, is a gram-negative, facultative anaerobe. The organism predominantly colonizes the gastrointestinal tract and, less often, the tissues, urine, and catheters. A 75-year-old male presented with a dry cough, fatigue, decreased appetite, intermittent disorientation, and difficulty ambulating. He had a history of self-catheterization due to urinary retention. He was scheduled to undergo transcatheter aortic valve replacement for enterococcal endocarditis. Physical examination was not significant for any changes. Urine analysis revealed positive leukocyte esterase, the presence of red and white blood cells, urine bacteria, and hyaline casts. The patient was started on empiric intravenous ceftriaxone. Urine culture grew Hafnia alvei and he was switched over to cefepime due to greater susceptibility. On day four, he started deteriorating clinically and was treated with four pressors but remained hypotensive and eventually became anuric. The patient developed septic shock with multiple organ dysfunction syndromes. Despite all measures, his clinical condition failed to improve, and he was continued with comfort measures only. The literature on Hafnia alvei-induced urosepsis is poor and fragmentary. Our patient showed resistance to most beta-lactam antibiotics, including cefuroxime, ceftriaxone, and ceftazidime, along with intermediate susceptibility to piperacillin/tazobactam and was managed with intravenous cefepime based on the sensitivity report. Inducible Bush group 1 beta-lactamase produced by Hafnia alvei is postulated to be responsible for antibiotic resistance. Physicians should remain vigilant of Hafnia alvei-induced urosepsis in patients with long-term catheterization initiating appropriate treatment.
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Affiliation(s)
- Keerthi Yarlagadda
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Isha Shrimanker
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Vinod K Nookala
- Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
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Abstract
Breast cancer is the most common cancer in women. The common sites of metastasis include the lungs, liver, and, infrequently, the gastrointestinal (GI) tract. A 72-year-old Caucasian female presented to the hospital with nausea and vomiting, diarrhea, intermittent abdominal pain, and unintentional weight loss. She had had a past medical history of bilateral lobular breast carcinoma and severe iron-deficiency anemia treated with iron transfusions. On arrival, the examination was significant for hypotension and pallor. Laboratory investigations revealed abnormal liver enzymes and raised tumor markers Ca-125 and carcinoembryonic antigen. Imaging studies established a diagnosis of distal small bowel obstruction. The surgical intervention showed the presence of a small bowel tumor, the biopsy findings of which were consistent with metastatic breast cancer, with ER and PR positive but HER-2 negative. She was managed with a selective estrogen receptor degrader and CDK4/6 inhibitor and has been in remission since. Metastasis to the small bowel from the breast is a very rare occurrence. Clinicians should thus maintain a modest amount of suspicion when encountering an uncommon GI presentation of primary breast malignancy. We describe the case of metastatic breast cancer with an atypical GI presentation.
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Affiliation(s)
| | | | | | - Janet Gomez
- Internal Medicine, UPMC Pinnacle, Harrisburg, USA
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Gangireddy M, Shrimanker I, Saintelia S, Nookala VK. Active Hepatitis C Leading to Refractory Thrombotic Thrombocytopenic Purpura - A Dubious Association and The Challenges Faced in Management. Cureus 2019; 11:e5147. [PMID: 31523575 PMCID: PMC6741384 DOI: 10.7759/cureus.5147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/16/2019] [Indexed: 11/17/2022] Open
Abstract
Acquired thrombotic thrombocytopenic purpura is a combination of thrombocytopenia with microangiopathic hemolytic anemia. A 62-year-old female was transferred from an outside hospital for rapidly worsening mental status and severe thrombocytopenia. Laboratory studies were significant for reduced hemoglobin and platelet count along with raised blood urea nitrogen, creatinine, and serum lactate dehydrogenase levels. Peripheral smear showed numerous schistocytes and further testing showed low ADAMTS13 activity, high ADAMTS13 inhibitor, and positive hepatitis C virus antibody with a high hepatitis C virus ribonucleic acid (RNA) load. The patient was diagnosed with acquired thrombotic thrombocytopenic purpura and started on plasma exchange and steroids. Since no response was achieved until day four of treatment, weekly rituximab was initiated. After the initial two doses of rituximab, she showed significant improvement clinically. ADAMTS13 levels returned back to normal. Cyclosporine was added, following which platelet counts were normalized. Cyclosporine was discontinued, plasma exchange and steroids were slowly tapered off. Follow-up visits showed that the patient is off treatment and continues to be in remission and on regular treatment for hepatitis C. Acquired thrombotic thrombocytopenic purpura is a hematological emergency. Our patient remained refractory to standard therapies and required rituximab and immunosuppressive agents like cyclosporine. We describe the association of active hepatitis C with acquired thrombotic thrombocytopenic purpura that was refractory to plasma exchange, high dose steroids and rituximab. As per our knowledge, this is the first case in the literature to describe a possible association between active hepatitis C and acquired thrombotic thrombocytopenic purpura.
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Affiliation(s)
- Mounika Gangireddy
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
| | - Isha Shrimanker
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
| | - Sandy Saintelia
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
| | - Vinod K Nookala
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
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15
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Gangireddy M, Sarao MS, Shrimanker I, Nookala VK. A Fatal Case of Vancomycin Associated Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome in a Septuagenarian. Cureus 2019; 11:e5015. [PMID: 31497445 PMCID: PMC6716765 DOI: 10.7759/cureus.5015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but potentially life-threatening multi-system disorder with a mortality rate of up to 10%, due to severe hypersensitivity drug reaction involving the skin and multiple internal organ systems. We emphasize the increasing prevalence of DRESS syndrome secondary to vancomycin use. A 79-year-old woman presented to the hospital with complaints of right upper quadrant pain, intense pruritis, and jaundice of one-week duration. She was on vancomycin and cefepime for six weeks after a wound infection, and both the medicines were withheld a week ago due to the increasing creatinine. She was afebrile with a pulse-94/min, blood pressure-92/46 mm of Hg, and respiratory rate-14/min. She had scleral icterus, diffuse maculopapular rash, generalized edema, right upper quadrant tenderness, and a positive Murphy’s sign. Investigations revealed hemoglobin-10.5 gm/dl, white blood cell count-16.0 K/uL, peripheral eosinophil count-1730 K/uL, alkaline phosphatase-2742 U/L, aspartate transaminase-612 U/L, alanine transaminase-674 U/L, total bilirubin-14.2 mg/dl with a direct component of 9.5mg/dl, blood urea nitrogen-64 mg/dl, creatinine-5.01 mg/dl, glomerular filtration rate-8 ml/min and vancomycin trough level-10.8 mcg/ml. Imaging studies were unremarkable. The renal function improved after high dose steroids, N-acetylcysteine and withdrawal of vancomycin, but the progression of liver failure continued. Eventually, she passed away due to multiorgan failure. Vancomycin is a rare drug to cause DRESS syndrome with 31 cases reported to date. Early recognition of this condition can hasten proper treatment and recovery. Further research on the association of vancomycin trough levels and DRESS syndrome needs to be conducted.
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Affiliation(s)
- Mounika Gangireddy
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
| | | | - Isha Shrimanker
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
| | - Vinod K Nookala
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
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Yarlagadda K, Singh P, Shrimanker I, Hoffman JC, Nookala VK. Pot smokers puffing away lung health. Heart Lung 2019; 48:462-464. [PMID: 31128895 DOI: 10.1016/j.hrtlng.2019.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/09/2019] [Accepted: 05/14/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Marijuana is the second most commonly used inhalational agent after tobacco. It has been used for therapeutic benefits in cancer, epilepsy, inflammation and pain. Inhalation of marijuana causes reversible and irreversible lung injury. CASE We present a 26-year-old female with cough, chest pain, epistaxis, hemoptysis, night sweats and breathlessness few hours after smoking marijuana. Physical exam was positive for tachycardia, tachypnea, and diminished coarse breath sounds. Further investigation revealed elevated white blood cell count, chest X-ray, computed tomography of the chest showed bilateral patchy infiltrates. The patient was managed with short term steroid, as antibiotics alone did not work. Radiological improvement of lung injury was noted within 36-48 h. CONCLUSION There is a paucity of treatment guidelines for acute lung injury secondary to marijuana inhalation. We advocate early use of short-term steroids and also more awareness on quitting marijuana smoking to prevent life-threatening complications like myocardial infarction, diffuse alveolar hemorrhage and acute respiratory distress syndrome.
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Affiliation(s)
- Keerthi Yarlagadda
- Department of Internal Medicine, UPMC Pinnacle, 205 S Front St, Suite 3C, Harrisburg, PA 17104, USA
| | - Pratiksha Singh
- Department of Internal Medicine, UPMC Pinnacle, 205 S Front St, Suite 3C, Harrisburg, PA 17104, USA
| | - Isha Shrimanker
- Department of Internal Medicine, UPMC Pinnacle, 205 S Front St, Suite 3C, Harrisburg, PA 17104, USA.
| | - Joshua C Hoffman
- Pulmonary & Critical Care Medicine Associates, Harrisburg, PA, USA
| | - Vinod K Nookala
- Department of Internal Medicine, UPMC Pinnacle, 205 S Front St, Suite 3C, Harrisburg, PA 17104, USA
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Abstract
Spontaneous tumor lysis syndrome is a rare oncological emergency associated with multiorgan failure. It is characterized by an elevation of uric acid, hyperphosphatemia, hypocalcemia, hyperkalemia and renal failure in the setting of no active chemotherapy as a result of lysis of massive tumor burden. Early recognition of the disease and prompt management would affect morbidity and mortality. We present the case of an 80-year-old Caucasian male with a history of recently diagnosed diffuse large B-cell lymphoma who had worsening fatigue, weakness and decreased appetite for three days. On admission, laboratory investigations were significant for elevated creatinine, uric acid, and phosphorous. He was started on hemodialysis and rasburicase in view of hyperuricemia. Subsequently, chemotherapy was started. He tolerated chemotherapy initially but later developed multiorgan failure. His family then opted for comfort measures and the patient passed away soon after. In conclusion, spontaneous tumor lysis syndrome is a common association with hematological cancers. Prophylaxis with allopurinol and rasburicase is recommended in all patients who are at an increased risk for tumor lysis syndrome.
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Affiliation(s)
- Mounika Gangireddy
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
| | - Isha Shrimanker
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
| | - Vinod K Nookala
- Internal Medicine, University of Pittsburgh Medical Center - UPMC - Pinnacle, Harrisburg, USA
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