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Cataletti G, Santagata F, Pastorelli L, Battezzati PM. Severe azathioprine-induced liver injury 22 months after initiation of treatment. Drug Ther Bull 2024; 62:60-63. [PMID: 38302287 DOI: 10.1136/dtb.2024.253505rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Giovanni Cataletti
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Fabrizio Santagata
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Luca Pastorelli
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Pier Maria Battezzati
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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Vaselli NM, Du Preez S, Jasenthu Kankanamage N. Clozapine-induced pneumonitis mimicking an atypical pneumonia. BMJ Case Rep 2024; 17:e259154. [PMID: 38531554 DOI: 10.1136/bcr-2023-259154] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
Clozapine is an antipsychotic used for treatment-resistant schizophrenia with a significant side effect profile, including agranulocytosis, myocarditis and fever. Clozapine-induced fever often occurs in the first 2 weeks of treatment and settle after a few days. We report a case of a woman in her mid-30s who developed fever and infective symptoms suggestive of an atypical pneumonia while on clozapine titration. She was on clozapine for 16 days before developing high-grade fever, dry cough, diarrhoea, headache and photophobia with a very high CRP. We performed an extensive infection workup that returned negative results except for bilateral upper lobe ground glass changes of the lungs on CT. Despite antibiotic therapy, which would cover an atypical pneumonia, her CRP remained elevated and her fever persisted. Focus was directed to clozapine-induced pneumonitis as the cause for her symptoms. Her antibiotics were ceased, and clozapine was downtitrated. With the adjustment of her clozapine dose, her fevers and associated symptoms resolved, and CRP downtrended. Her fevers did not return when clozapine was uptitrated in the community subsequently. Clozapine-induced fever or other immune-allergic reactions should be systematically considered when patients develop fever during the initiation phase of clozapine therapy. Ruling out infective causes is desirable prior to attributing fevers to clozapine especially when they are accompanied by infective symptoms and high inflammatory markers. Careful downtitration of clozapine should be considered rather than abrupt cessation in managing clozapine-induced fevers and subsequent slow uptitration could be considered.
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Affiliation(s)
- Natasha Marcella Vaselli
- General Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, UK
| | - Stanley Du Preez
- General Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
| | - Nuwan Jasenthu Kankanamage
- General Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
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Jarman GL, Webb GJ. Delayed drug-induced liver injury (DILI) and flare of chronic plaque psoriasis secondary to lisinopril use. BMJ Case Rep 2024; 17:e256317. [PMID: 38262719 PMCID: PMC10826484 DOI: 10.1136/bcr-2023-256317] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
Lisinopril is an ACE inhibitor commonly used in the treatment of cardiovascular and renal disease. Rarely, ACE inhibitors have been associated with cholestatic jaundice and hepatitis, with potential risk of fulminant hepatic failure if continued. There is limited information available regarding the risk of hepatic failure secondary to lisinopril use, with a handful of case reports demonstrating drug-induced liver injury at varying time scales from drug initiation. In this case, we present a man with symptoms of cholestatic jaundice, a blistering skin rash and flare of chronic plaque psoriasis, 27 months after lisinopril initiation for hypertension. Biochemical, serological and radiological investigations of an alternative cause for his jaundice were unremarkable. Cessation of lisinopril led to a rapid and sustained improvement in liver biochemistry and a significant improvement in his chronic plaque psoriasis.
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Affiliation(s)
- Georgeina L Jarman
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gwilym J Webb
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Chakraborty U, Banerjee S, Chandra A, Sil A. Amantadine-induced livedo racemosa. BMJ Case Rep 2024; 17:e257492. [PMID: 38216170 PMCID: PMC10806849 DOI: 10.1136/bcr-2023-257492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024] Open
Affiliation(s)
- Uddalak Chakraborty
- Neurology, Institute of Postgraduate Medical Education and Research Bangur Institute of Neurology, Kolkata, India
| | - Soumozit Banerjee
- Neurology, Institute of Postgraduate Medical Education and Research Bangur Institute of Neurology, Kolkata, India
| | - Atanu Chandra
- Internal Medicine, RG Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Abheek Sil
- Dermatology, Venereology, and Leprosy, RG Kar Medical College and Hospital, Kolkata, West Bengal, India
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Meunier A, Goffin P, Deville M, Demaret P. Intravenous lipid emulsion for a life-threatening prothipendyl intoxication. BMJ Case Rep 2024; 17:e256417. [PMID: 38199666 PMCID: PMC10806955 DOI: 10.1136/bcr-2023-256417] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Prothipendyl, a lipophilic neuroleptic drug, requires a careful dosage regimen due to its potential side effects, including life-threatening arrhythmias.This report outlines a case of severe prothipendyl intoxication, its management and the successful utilisation of Intralipid, an intravenous lipid emulsion, in treating ventricular arrhythmia postmassive prothipendyl ingestion. Additionally, the mechanism of action of Intralipid and the rebound concentration of the lipophilic drug in such scenarios are discussed.
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Affiliation(s)
- Anne Meunier
- Anesthesia and Intensive Care, Montlegia Hospital, Groupe Santé CHC, Liège, Belgium
| | - Pierre Goffin
- Anesthesia and Intensive Care, Montlegia Hospital, Groupe Santé CHC, Liège, Belgium
| | - Marine Deville
- Laboratory of Clinical, Forensic, Industrial and Environmental Toxicology, Center for Interdisciplinary research on Medicines, University Hospital of Liège, Liege, Belgium
| | - Pierre Demaret
- Anesthesia and Intensive Care, Montlegia Hospital, Groupe Santé CHC, Liège, Belgium
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Addiego AM, Razi S, Li H. Avatrombopag-induced lactic acidosis in a patient with severe thrombocytopenia. BMJ Case Rep 2023; 16:e256463. [PMID: 38061849 PMCID: PMC10711905 DOI: 10.1136/bcr-2023-256463] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
A woman in her 60s was admitted for refractory thrombocytopenia, initially presumed to be from immune thrombocytopenia (ITP). She was treated with the thrombopoietin receptor agonist (TPO-RA) avatrombopag, as well as prophylactic ciprofloxacin and fluconazole for neutropenia. She developed an anion gap metabolic acidosis with a significantly elevated lactate level peaking at 7.5 mmol/L. Other causes of lactic acidosis including hypovolaemia, sepsis, ischaemia and diabetic ketoacidosis were ruled out. Avatrombopag was discontinued, with quick resolution of the lactic acidosis. Fluconazole and ciprofloxacin were found to inhibit the metabolism of avatrombopag and were also discontinued. Worsening thrombocytopenia prompted a rechallenge with increased dose avatrombopag and severe lactic acidosis again developed, with subsequent quick resolution after drug discontinuation. We conclude that a dose-dependent lactic acidosis occurred with avatrombopag in this case. While other TPO-RAs including eltrombopag have been associated with lactic acidosis, to our knowledge, this is the first report of avatrombopag-induced lactic acidosis.
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Affiliation(s)
| | - Samrah Razi
- Washington University in St Louis, St Louis, Missouri, USA
| | - Han Li
- Washington University in St Louis, St Louis, Missouri, USA
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Cho Y, Inoue K, Kunimoto M, Minamino T. Haemodynamic effects of acute intravenous landiolol in Takotsubo cardiomyopathy with dynamic left ventricular outflow tract obstruction. BMJ Case Rep 2023; 16:e255987. [PMID: 37844977 PMCID: PMC10583023 DOI: 10.1136/bcr-2023-255987] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
Takotsubo cardiomyopathy (TCM) leads to serious left ventricular outflow tract (LVOT) obstruction with cardiogenic shock in 6%-20% of cases. The onset of LVOT obstruction, coupled with mitral regurgitation resulting from systolic anterior motion of mitral valve leaflets, can lead to haemodynamic instability in addition to severely impaired systolic function. We describe three patients who experienced chest discomfort following emotional stress. These patients displayed pronounced abnormalities on ECGs, insignificant obstructive coronary disease and haemodynamic instability due to LVOT obstruction. The infusion of landiolol, a short-acting beta blocker, was effective in releasing the gradient. Dynamic outflow obstruction is the major predictor of haemodynamic collapse. We suggested that an early identification of this complication in hypotensive patients with suspected TCM could be of utmost importance to optimise the therapeutic approach in the acute setting.
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Affiliation(s)
- YeJi Cho
- Cardiovascular Biology and Medicine, School of Medicine, Graduate School of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Kenji Inoue
- Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital, Nerima-ku, Tokyo, Japan
| | - Mitsuhiro Kunimoto
- Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital, Nerima-ku, Tokyo, Japan
| | - Tohru Minamino
- Cardiovascular Biology and Medicine, School of Medicine, Graduate School of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
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Akham R, Bhatia R, Paonam R, Hazarika N. Rescue treatment with intravenous immunoglobulin and amniotic membrane dressing in refractory paediatric pemphigus vulgaris with sepsis. BMJ Case Rep 2023; 16:e253507. [PMID: 37558274 PMCID: PMC10414109 DOI: 10.1136/bcr-2022-253507] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
We report a case of refractory paediatric pemphigus vulgaris with sepsis, treated successfully with intravenous immunoglobulin (IVIG) and amniotic membrane dressing. The patient was initially started on oral prednisolone (1 mg/kg/day) and dapsone 50 mg once daily. Azathioprine 50 mg orally was then used in place of dapsone due to rapid disease progression with extensive skin involvement. However, the patient developed sepsis and azathioprine had to be discontinued. Because of rapidly progressive disease and sepsis, the patient was put on IVIG at a dose of 2 g/kg in divided doses over 3 days along with amniotic membrane dressing. There was marked improvement after 2 weeks of follow-up.
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Affiliation(s)
- Rojita Akham
- Dermatology, Venereology & Leprosy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Riti Bhatia
- Dermatology, Venereology & Leprosy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Rikita Paonam
- Dermatology, Venereology & Leprosy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Neirita Hazarika
- Dermatology, Venereology & Leprosy, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Okumura H, Kawashima A. Black hairy tongue due to antibiotics. BMJ Case Rep 2023; 16:e255112. [PMID: 37524513 PMCID: PMC10391799 DOI: 10.1136/bcr-2023-255112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Affiliation(s)
- Hisatoshi Okumura
- Department of Generel Internal Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Atsushi Kawashima
- Department of Generel Internal Medicine, Fukuchiyama City Hospital, Fukuchiyama, Japan
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Choudhry B, Mitchell J, Milner S. A surgeon's trial success of curing pedal eumycetoma. BMJ Case Rep 2023; 16:e218559. [PMID: 37507126 PMCID: PMC10387635 DOI: 10.1136/bcr-2016-218559] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023] Open
Abstract
Mycetoma is a chronic infection of underlying fungal (eumycetoma) or bacterial (actinomycetoma) origin. It is characterised by a clinical triad of tumour-like swelling, actively draining sinuses and macroscopic grains of characteristic colours.We the case of a 66-year-old woman on immunosuppressive therapy presenting with eumycetoma of the foot (Madura foot). The fungal organism cultured was Acrophialophora fusisporaThis case was managed with a combination of extensive surgical debridement, and packing with calcium sulfate (Stimulan) beads impregnated with vancomycin and voriconazole. As far as the authors are aware, this is a novel adjunct to the surgical treatment of deep fungal infection in the foot.Eumycetoma treated with surgery and oral antifungal therapy leads to cure rates of 25%-35%. This novel treatment seems to bear further investigation for the potential to improve cure rates. At 8 months follow-up, our patient appears to be making good progress with no current signs of recurrence.
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Costa L, Costa M, Martins J, Castro R. Polymyoclonus, ventricular fibrillation and Takotsubo after accidental spinal injection of tranexamic acid. BMJ Case Rep 2023; 16:e251814. [PMID: 37463777 DOI: 10.1136/bcr-2022-251814] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Several factors have been identified as contributing to medication administration errors, including look-alike, sound-alike (LASA) errors. LASA errors are important causes of serious adverse events arising from spinal injection of tranexamic acid, which can be confused with ampoules of local anaesthesia.We present a case of accidental injection of 250 mg of tranexamic acid rather than prilocaine during spinal anaesthesia. The patient developed lower extremities myoclonus, followed by generalised convulsions and ventricular fibrillation, that was reverted within 6 min. Severe cardiogenic shock requiring both inotropic and vasopressor therapy followed, along with a classic apical ballooning pattern on echocardiography and elevated myocardial injury markers, indicating Takotsubo cardiomyopathy. The patient's condition progressively improved to full recovery, and she was discharged from hospital after 1 month with no neurological deficit or cardiac dysfunction.To our knowledge, this is the 28th reported case of accidental spinal injection of tranexamic acid. We present a brief review of previously published cases.
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Affiliation(s)
- Laura Costa
- Intensive Care Medicine, Hospital of Braga, Braga, Portugal
| | - Marina Costa
- Intensive Care Medicine, Hospital of Braga, Braga, Portugal
| | - José Martins
- Intensive Care Medicine, Hospital of Braga, Braga, Portugal
| | - Rui Castro
- Intensive Care Medicine, Hospital of Braga, Braga, Portugal
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McFadzean IJ, Davies K, Purchase T, Edwards A, Hellard S, Ashcroft DM, Avery AJ, Flynn S, Hewson T, Jordan M, Keers R, Panagioti M, Wainwright V, Walter F, Shaw J, Carson-Stevens A. Patient safety in prisons: a multi-method analysis of reported incidents in England. J R Soc Med 2023:1410768231166138. [PMID: 37196674 PMCID: PMC10387805 DOI: 10.1177/01410768231166138] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVES Prisoners use healthcare services three times more frequently than the general population with poorer health outcomes. Their distinct healthcare needs often pose challenges to safe healthcare provision. This study aimed to characterise patient safety incidents reported in prisons to guide practice improvement and identify health policy priorities.Design: We carried out an exploratory multi-method analysis of anonymised safety incidents from prisons. SETTING Safety incidents had been reported to the National Reporting and Learning System by prisons in England between April 2018 and March 2019. PARTICIPANTS Reports were reviewed to identify any unintended or unexpected incident(s) which could have, or did, lead to harm for prisoners receiving healthcare. MAIN OUTCOME MEASURES Free-text descriptions were examined to identify the type and nature of safety incidents, their outcomes and harm severity. Analysis was contextualised with subject experts through structured workshops to explain relationships between the most common incidents and contributory factors. RESULTS Of 4112 reports, the most frequently observed incidents were medication-related (n = 1167, 33%), specifically whilst administering medications (n = 626, 54%). Next, were access-related (n = 559,15%), inclusive of delays in patients accessing healthcare professionals (n = 236, 42%) and managing medical appointments (n = 171, 31%). The workshops contextualised incidents involving contributing factors (n = 1529, 28%) into three key themes, namely healthcare access, continuity of care and the balance between prison and healthcare priorities. CONCLUSIONS This study highlights the importance of improving medication safety and access to healthcare services for prisoners. We recommend staffing level reviews to ensure healthcare appointments are attended, and to review procedures for handling missed appointments, communication during patient transfers and medication prescribing.
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Affiliation(s)
- Isobel J McFadzean
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK
| | - Kate Davies
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK
| | - Thomas Purchase
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK
| | - Adrian Edwards
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK
| | - Stuart Hellard
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, Manchester, M13 9PL, UK
| | - Anthony J Avery
- NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, Manchester, M13 9PL, UK
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Sandra Flynn
- Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK
| | - Tom Hewson
- Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK
| | - Melanie Jordan
- School of Sociology & Social Policy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Richard Keers
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Foundation Trust (GMMH), Manchester, M25 3BL, UK
| | - Maria Panagioti
- NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, Manchester, M13 9PL, UK
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, M13 9NT, UK
| | - Verity Wainwright
- Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK
| | - Florian Walter
- Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK
| | - Jenny Shaw
- Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Foundation Trust (GMMH), Manchester, M25 3BL, UK
- Independent Advisory Panel on Deaths in Custody, London, SW1H 9AJ, UK
| | - Andrew Carson-Stevens
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK
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Molinari G, Rosti A, Presutti L, Marzocchi G. Laryngeal tuberculosis in patients treated with adalimumab: a casual or causal connection? BMJ Case Rep 2023; 16:16/4/e254742. [PMID: 37041038 PMCID: PMC10105991 DOI: 10.1136/bcr-2023-254742] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
This article presents two consecutive cases of laryngeal tuberculosis in patients treated with a specific anti-tumour necrosis factor-alpha (adalimumab), with a focus on their diagnostic process and therapeutic management. Both patients presented with aspecific chronic laryngeal symptoms that had been worsening for a few months in one case and for almost 1 year in the other one. They were both studied with fibreoptic laryngoscopy and contrast-enhanced CT and MRI scans. In both cases, the laryngeal biopsy proved negative to Ziehl-Neelsen test, while positive to Koch's bacillus sensitive to rifampicin at PCR test. Both patients completely responded to standard antitubercular antibiotic therapy with rifampicin, isoniazid, pyrazinamide and etambutol protocol.In the differential diagnosis of such patients, laryngeal tuberculosis should be considered due to the reasonable linkage between the immunosuppressant therapy with adalimumab and the tuberculosis infection/reactivation.
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Affiliation(s)
- Giulia Molinari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Alessandro Rosti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Livio Presutti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | - Guido Marzocchi
- Emergency Radiology, Azienda Ospedaliero-Universitaria di Bologna IRCCS, Bologna, Italy
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Lim JHB, Robinson B, Savige J. Delayed-Onset olanzapine-induced rhabdomyolysis. BMJ Case Rep 2023; 16:16/3/e254377. [PMID: 36898712 PMCID: PMC10008316 DOI: 10.1136/bcr-2022-254377] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Olanzapine is a commonly used and effective second-generation antipsychotic agent used for the control of paranoia and agitation in schizophrenia and bipolar disorder as well as in the behavioural and psychological symptoms of dementia. Serious side effects of treatment are uncommon but spontaneous rhabdomyolysis represents a rare complication. We describe here a patient treated with a stable dose of olanzapine for more than 8 years who developed acute severe rhabdomyolysis without an identifiable trigger and without features suggestive of neuroleptic malignant syndrome. The rhabdomyolysis was atypical in its delayed onset and severity with a creatine kinase level of 345 125 U/L, the highest level reported in the available literature. We also describe the clinical manifestations of delayed-onset olanzapine-induced rhabdomyolysis and its differentiation from neuroleptic malignancy syndrome, and we highlight key aspects of management to prevent or minimise further complications such as acute kidney injury.
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Affiliation(s)
- Jun Hua Bowen Lim
- General Medicine, The Northern Hospital, Epping, Victoria, Australia
| | - Billy Robinson
- General Medicine, The Northern Hospital, Epping, Victoria, Australia
| | - Judith Savige
- General Medicine, The Northern Hospital, Epping, Victoria, Australia
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Safia A, Farhat R, Avraham Y, Merchavy S. Kaposi sarcoma at the base of the tongue in a renal transplant patient. BMJ Case Rep 2023; 16:16/3/e253899. [PMID: 36882263 PMCID: PMC10008222 DOI: 10.1136/bcr-2022-253899] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Oral Kaposi Sarcoma (OKS) commonly occurs in patients with AIDS. The incidence of Kaposi sarcoma (KS) is greatly increased in renal transplant recipients compared with the general population, with particular prevalence in certain ethnic groups where it can occur in up to 5% of transplant recipients. From them, only 2% can manifest first with OKS.A man in his early 40s, 2 years after kidney transplantation, presented with a reddish-purple hypertrophic ulcerated lesion at the base of the tongue. Cervical ultrasonography revealed enlarged lymph nodes, and pathological examination of biopsies revealed KS. The patient had HIV-negative status. Following an investigation, calcineurin inhibitor treatment was stopped, and an mTOR (mammalian target of rapamycin) inhibitor treatment was started. Fibreoptic examination 3 months after beginning mTOR inhibitor treatment revealed no traces of the disease in the base of the tongue.An isolated oral lesion should not distract clinicians from further systemic investigation for metastatic disease.OKS is a rare but serious complication in kidney transplant patients after receiving calcineurin inhibitor that could result in airway obstruction due to mass effect or bleeding and aspiration.Early diagnosis and management of OKS in a renal transplant patient who received a calcineurin inhibitor carry a good prognosis. OKS can be managed by changing the treatment regime to an mTOR inhibitor followed by radiation therapy. This contrasts with KS treatment in non-renal transplant patients without calcineurin inhibitors who may need treatment using different modalities such as surgery and chemotherapy.We emphasise the importance of this case for nephrologists responsible for patient follow-up after renal transplantation who prescribed calcineurin inhibitors. These patients must be advised that if they feel any physical mass in the tongue, they should immediately seek an examination by an ear, nose and throat specialist. Nephrologists and patients should be aware that these symptoms should not be underestimated.
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Affiliation(s)
- Alaa Safia
- Otolaryngology Department, Ziv Medical Center, Safed, Israel
| | - Raed Farhat
- Otolaryngology Department, Ziv Medical Center, Safed, Israel
| | - Yaniv Avraham
- Otolaryngology Department, Ziv Medical Center, Safed, Israel
| | - Shlomo Merchavy
- Otolaryngology Department, Ziv Medical Center, Safed, Israel
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16
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Babu VK, Rojas P, Perez Del Nogal G, Garcia-Fernandez A. Unusual case of propofol-related infusion syndrome complicating severe COVID-19 ARDS. BMJ Case Rep 2023; 16:16/2/e249456. [PMID: 36750301 PMCID: PMC9906275 DOI: 10.1136/bcr-2022-249456] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
An elderly man presenting with shortness of breath and hypoxaemia was admitted with acute hypoxic respiratory failure secondary to COVID-19 pneumonia. Due to worsening hypoxaemia, he was transferred to the intensive care unit and required mechanical ventilation. Propofol was infused at 1.5-4 mg/kg/hour. Within 48 hours of initiation, we noticed worsening metabolic acidosis, acute kidney injury, hyperkalaemia, hyperphosphataemia, hypertriglyceridaemia, elevated creatine kinase and elevated myoglobin levels. Suspecting propofol-related infusion syndrome (PRIS), we discontinued his propofol infusion immediately and initiated supportive measures. In 48 hours, there was a significant improvement in metabolic acidosis, hypertriglyceridaemia, rhabdomyolysis and renal function. The propofol infusion rate and cumulative propofol dosage (under 140 mg/kg) were well below levels associated with PRIS. COVID-19's pathogenesis, still under investigation, may have contributed to this presentation. It is imperative for clinicians to maintain a high degree of suspicion once propofol is initiated, regardless of the cumulative dose or rate of infusion.
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Affiliation(s)
- Vedesh Kumar Babu
- Internal Medicine Residency, Texas Tech University Health Sciences Center School of Medicine, Odessa, Texas, USA
| | - Pedro Rojas
- Internal Medicine Residency, Texas Tech University Health Sciences Center School of Medicine, Odessa, Texas, USA
| | - Genesis Perez Del Nogal
- Internal Medicine Residency, Texas Tech University Health Sciences Center School of Medicine, Odessa, Texas, USA
| | - Alejandra Garcia-Fernandez
- Internal Medicine Residency, Texas Tech University Health Sciences Center School of Medicine, Odessa, Texas, USA
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17
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Rashid K, Waheed MA, Khan Y, Afridi A, Ansar F, Elzouki A. Pneumomediastinum in association with Covid-19: A less commonly considered differential diagnosis for worsening respiratory failure. Qatar Med J 2023; 2023:4. [PMID: 36606063 PMCID: PMC9811311 DOI: 10.5339/qmj.2023.4] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 11/08/2022] [Indexed: 01/05/2023] Open
Abstract
We have reported here two cases of coronavirus disease-2019 (COVID-19) patients aged 29 and 68 years who were diagnosed with pneumomediastinum (PM). PM is a rare complication that is being reported in association with COVID-19. Patients with COVID-19 can present with a variety of etiologies that make them vulnerable to PM. Respiratory complications due to COVID-19 are widely known, and it presents as mild to severe and critical illness. Spontaneous PM is a known complication of COVID-19. Despite seeming to be a lesser-known condition, PM can have a significant impact on disease progression and prognosis. We have presented here two contrasting cases of PM. The first patient was young and with moderate COVID-19 pneumonia and PM, while the second one was an old man with severe COVID-19 pneumonia manifestations. Both patients were diagnosed with PM, but their outcomes were completely different.
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Affiliation(s)
| | - Muhammad Aamir Waheed
- Hamad Medical Corporation, Qatar. E-mail: ORCID: E-mail: 0000-0002-9056-5245,E-mail: ORCID: E-mail: 0000-0002-9056-5245
| | | | - Adnan Afridi
- Northampton General Hospital NHS Trust, Acute Medicine
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18
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Cataletti G, Santagata F, Pastorelli L, Battezzati PM. Severe azathioprine-induced liver injury 22 months after initiation of treatment. BMJ Case Rep 2022; 15:15/12/e253505. [PMID: 36543371 PMCID: PMC9772668 DOI: 10.1136/bcr-2022-253505] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Drug-induced liver injury (DILI) is the leading cause of acute liver failure in high-income countries. Acute cholestasis is one of the most common forms of hepatotoxicity induced by azathioprine. It usually begins during the first year of treatment, with most cases reported during the first month. We describe an uncommon case of DILI that occurred after 22 months of drug administration. A woman in her 50s was hospitalised because of jaundice and asthenia. She had been treated with azathioprine for myasthenia gravis during the last 2 years. Acute cholestatic injury was diagnosed. After ruling out most common causes of cholestasis, azathioprine was withdrawn and subsequent histological findings in liver biopsy were consistent with drug-induced cholestatic liver damage. After discontinuation of azathioprine, biochemical parameters progressively normalised and remarkable clinical improvement was achieved. With this report, we suggest that azathioprine should be considered among the causes of liver injury, despite long treatment duration.
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Affiliation(s)
- Giovanni Cataletti
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy .,Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Fabrizio Santagata
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy.,Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Luca Pastorelli
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy.,Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Pier Maria Battezzati
- Liver and Gastroenterology Unit, ASST Santi Paolo e Carlo, Milan, Italy.,Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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19
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Maldar SB, Pinto CJ. Homozygous familial hypercholesterolaemia in a patient presenting with hypertensive encephalopathy. BMJ Case Rep 2022; 15:15/10/e250265. [PMID: 36316049 PMCID: PMC9628547 DOI: 10.1136/bcr-2022-250265] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Homozygous familial hypercholesterolaemia (HoFH) is a disorder affecting low-density lipoprotein (LDL) receptor genes. Patients typically have a triad of elevated LDL-cholesterol (LDL-C), xanthomatosis and premature atherosclerotic cardiovascular disease. Our patient, a preteen boy, presented with signs of hypertensive encephalopathy. Physical examination showed arcus cornealis, planar xanthomas and tuberous xanthomas. After appropriate investigations, a direct aetiology of the hypertension could not be elucidated; however, our patient's hypertension resolved with the reduction in serum lipid levels. β-hydroxy β-methylglutaryl coenzyme A reductase and cholesterol absorption inhibitors were administered as first-line treatment. A significant proportion of patients with HoFH continue to have elevated LDL-C levels, thereby requiring second-line agents, such as proprotein convertase subtilisin/kexin type inhibitors (evolocumab), microsomal triglyceride transfer protein inhibitors (lomitapide) and angiopoietin-like protein inhibitors (evinacumab). This case report aimed to raise awareness among paediatricians to consider HoFH as a possible aetiology in a child presenting with hypertension and suggestive physical findings.
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Affiliation(s)
- Shadab B Maldar
- Department of Pediatric Medicine, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
| | - Christopher Jude Pinto
- Department of Internal Medicine, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
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20
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Singh N, Singh R, Decker B, Robins D, Vidal G. Metastatic triple negative breast cancer with NTRK gene fusion on tissue but not on ctDNA molecular profile. BMJ Case Rep 2022; 15:15/10/e251656. [PMID: 36223973 PMCID: PMC9562290 DOI: 10.1136/bcr-2022-251656] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
A woman presented to medical oncology with almost 4 years of untreated, slowly progressing, triple negative metastatic breast cancer to the lung. About 15 years prior, she was diagnosed with invasive ductal carcinoma of the right breast with ipsilateral chest wall recurrence 6 years later. Comprehensive molecular profiling of a metastatic lesion detected a hotspot ETV6-NTRK3 fusion, which was not present on circulating tumour DNA or molecular profile performed 4 years prior. A second look pathological examination demonstrated tumour characteristics consistent with secretory breast carcinoma. Identification of ETV6--NKRT3 fusion allowed for treatment with larotrectinib, a tyrosine kinase inhibitor specifically indicated for secretory breast carcinoma. After 3 months, she experienced a partial response.
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Affiliation(s)
- Nupur Singh
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Rishika Singh
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Brennan Decker
- West Cancer Center and Research Institute, Memphis, TN, USA
| | - David Robins
- West Cancer Center and Research Institute, Memphis, TN, USA
| | - Gregory Vidal
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,West Cancer Center and Research Institute, Memphis, TN, USA
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21
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Hones K, Krekora U, Nasri E, Altshuler E. Metastatic malignant peripheral nerve sheath tumour in a patient with neurofibromatosis 1 and review of contemporary systemic treatments. BMJ Case Rep 2022; 15:e250462. [PMID: 36192032 PMCID: PMC9535141 DOI: 10.1136/bcr-2022-250462] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Malignant peripheral nerve sheath tumours are rare soft tissue sarcomas commonly seen in patients with neurofibromatosis type 1. They typically manifest in the fibrous sheaths of major nerve trunks in the extremities or in an axial location. Presenting symptoms are generally non-specific, including pain and weakness, and survival is dependent on size and location of the tumour. Surgical resection is the primary treatment modality followed by radiotherapy or chemotherapy; however, prognosis is poor. Medications such as tyrosine kinase inhibitors and mitogen-activated protein kinase (MAPK)/extracellular signal-regulated kinase (ERK) pathway inhibitors are increasingly being recognised as potentially effective therapy for these malignancies. We report a case of a patient with neurofibromatosis type 1 presenting with a malignant peripheral nerve sheath tumour along the tibial nerve that was initially diagnosed as a muscle strain. We discuss the utility of diagnostic imaging and pathology in correctly identifying this aggressive tumour as well as review the drugs used in her care.
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Affiliation(s)
- Keegan Hones
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Urszula Krekora
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Elham Nasri
- Department of Pathology, Immunology and Laboratory Health, University of Florida Health, Gainesville, Florida, USA
| | - Ellery Altshuler
- Internal Medicine, University of Florida, Gainesville, Florida, USA
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22
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Abstract
Superwarfarin (long-acting anticoagulant rodenticide) poisoning should be suspected in unexplained bleeding with prolonged prothrombin time, especially in the absence of another explanation. Diagnosis and treatment of this intoxication remain a challenge as the direct analysis of superwarfarin in serum is not always possible. Therefore, toxin bioavailability remains unknown and close monitoring and treatment for long periods are required to avoid serious bleeding complications. Here, we discuss a case of suspected superwarfarin poisoning to highlight the challenges in early diagnosis and the challenges we encountered in treatment management and ensuring compliance for long periods.
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Affiliation(s)
| | | | - Carla Moret Puig
- Haematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
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23
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Colbenson GA, Kubbara A, Cox CW, Yi ES, Baqir M. Excipient lung disease secondary to intravenous heroin use. BMJ Case Rep 2022; 15:e247763. [PMID: 35450874 PMCID: PMC9024198 DOI: 10.1136/bcr-2021-247763] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/03/2022] Open
Abstract
We present a case of a woman who had progressive shortness of breath and wheezing with a mild restrictive pulmonary function pattern. She was initially diagnosed with eosinophilic granulomatosis with polyangiitis on the basis of peripheral eosinophilia, bronchoalveolar lavage eosinophilia (47%) and surgical lung biopsy findings. Six months following her diagnosis, the patient returned because of persistent symptoms, and a second review of the lung biopsy revealed thrombotic lesions in the pulmonary vessels with polarisable foreign body materials, associated giant cell reactions and numerous eosinophil infiltrates, consistent with intravenous drug abuse. Further investigation showed that she had a history of intravenous heroin overdose, and the diagnosis of excipient lung disease was made. This case highlights the importance of expert pathological, radiological and clinical review of complex presentations and the need for a thorough medication and drug use history review.
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Affiliation(s)
| | - Aahd Kubbara
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christian W Cox
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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24
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Byrne EM, Khattab A, Chen F, Bhagavatula R. Rare presentation of enoxaparin-induced skin necrosis in a postoperative patient. BMJ Case Rep 2022; 15:e249685. [PMID: 35418382 PMCID: PMC9013989 DOI: 10.1136/bcr-2022-249685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 01/18/2023] Open
Abstract
Enoxaparin-induced skin necrosis is a rare complication of low-molecular weight heparin (LMWH) therapy. We describe a woman in her 50s who developed deep vein thrombosis (DVT), thrombocytopenia and necrotic skin lesions after initiation of enoxaparin for DVT prophylaxis. Despite high clinical suspicion of heparin-induced thrombocytopenia syndrome and a positive heparin-platelet factor 4 antibody, heparin serotonin assay was negative. This case emphasises the importance for clinical vigilance regarding complications to LMWH therapy.
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Affiliation(s)
- Emma McNell Byrne
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Ahmed Khattab
- Division of Hematology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Feifan Chen
- Pathology Department, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Rama Bhagavatula
- Division of Hematology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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25
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Singh YP, Roy D, Jois B, Shetti M. Reactive arthritis following treatment with intravesical Bacillus Calmette-Guerin for papillary carcinoma of bladder. BMJ Case Rep 2022; 15:e249208. [PMID: 35418381 PMCID: PMC9014044 DOI: 10.1136/bcr-2022-249208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/04/2022] Open
Abstract
A man in his 60s developed reactive arthritis following treatment with intravesical Bacillus Calmette-Guerin (iBCG) for papillary carcinoma of bladder. Evaluation revealed leucocytosis and raised inflammatory markers. HLA B27 was positive. Based on the temporal relationship, it was attributed to BCG-related reactive arthritis. iBCG was stopped. Treatment with non-steroidal anti-inflammatory drugs (NSAIDS) and glucocorticoids were ineffective. Prolonged course of disease-modifying antirheumatic drugs (DMARDS) was required which aided in alleviation of symptoms and sustained remission. Intravesical BCG therapy is a treatment for bladder cancer. It is rarely associated with reactive arthritis, which responds to discontinuation of iBCG and treatment with NSAIDS and/or short-term glucocorticoids. iBCG-related reactive arthritis commonly has an acute/subacute course. Chronic arthritis as observed in our case requiring prolonged treatment with DMARDS is rare.
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Affiliation(s)
- Yogesh Preet Singh
- Rheumatology, Manipal Hospital HAL Airport road, Bangalore, Karnataka, India
| | - Debaditya Roy
- Rheumatology, Manipal Hospital HAL Airport road, Bangalore, Karnataka, India
| | - Bhargavi Jois
- Nuclear Medicine, Manipal Hospital HAL Airport road, Bangalore, Karnataka, India
| | - Mohit Shetti
- Gastroenterology, Manipal Hospital HAL Airport road, Bangalore, Karnataka, India
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26
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Anjaneyan G, Keechilat P, Duraisamy P, Eapen M. Ribociclib-induced extensive vitiligo-like lesions: possible pathomechanisms with clinical, dermoscopic and histological correlation. BMJ Case Rep 2022; 15:e248782. [PMID: 35365472 PMCID: PMC8977742 DOI: 10.1136/bcr-2022-248782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 11/03/2022] Open
Abstract
Cyclin dependent kinase (CDK) 4/6 inhibitors are targeted agents which act on cyclin-D and these combined with hormonal therapy have been approved for the treatment of locally advanced or metastatic breast cancer. CDK 4/6 inhibitors have been found to have a tolerable adverse event profile; however, they have been associated with various dermatological adverse events. We report a case of ribociclib-induced vitiligo and discuss the clinical, dermoscopic and histological features with a review of the various possible pathomechanisms involved.
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Affiliation(s)
- Gopikrishnan Anjaneyan
- Department of Dermatology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Pavithran Keechilat
- Medical Oncology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Prasanna Duraisamy
- Department of Dermatology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Malini Eapen
- Department of Pathology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
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27
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Doyle C, Eustace K. Pompholyx as a side effect of intravenous immunoglobulin (IVIg). BMJ Case Rep 2022; 15:e248772. [PMID: 35354565 PMCID: PMC8968538 DOI: 10.1136/bcr-2022-248772] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/04/2022] Open
Abstract
Intravenous immunoglobulin (IVIg) is increasingly used across multiple specialties for the treatment of inflammatory and autoimmune diseases. Cutaneous reactions to IVIg are generally minor. Pompholyx is a common eruption of small vesicles on the palms, soles, and/or lateral aspects of the fingers. It has a multifactorial aetiology but is rarely attributed to being a drug-related side effect. We describe a 43-year-old woman presenting with peripheral sensory neuropathy who developed pompholyx eczema on both palms following treatment with IVIg.
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28
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Eren MT, Özveri H, Kurtoğlu H. Penile Mondor's in a Covid-19 patient on prophylactic anti-thrombosis with rivaroxaban: a case report. Afr J Urol 2021; 27:97. [PMID: 34248351 PMCID: PMC8258473 DOI: 10.1186/s12301-021-00200-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 03/18/2021] [Accepted: 06/29/2021] [Indexed: 01/21/2023] Open
Abstract
Background Penile Mondor's disease (PMD) is thrombophlebitis of the superficial dorsal vein of the penis. Following the occurrence of thrombotic events in the affected veins, the lumen often becomes occluded with fibrin and inflammatory cells. A hyper-coagulative state is one of the underlying causes although most cases of PMD are idiopathic. Coronavirus disease-2019 infection (COVID-19) is associated with frequent thrombotic events. Inflammation and thrombosis play a central role in the course and outcome of COVID-19, which can predispose to both venous and arterial thromboembolism. In this report, we present a 33-year-old male patient diagnosed with PMD during the subacute phase of COVID-19 infection while on prophylactic antithrombotic treatment. Case Presentation A 33-year-old male patient was diagnosed as PMD which occurred during the subacute phase of COVID-19 infection, while he was on active treatment of COVID-19 by prophylactic antithrombotic Rivaroxaban 15 mg therapy and curative antiviral medication. There was no recent sexual intercourse or trauma to the genitals. His PCR test for COVID-19 had become negative, and antibody test was positive at the time of his PMD's onset. Rivaroxaban was replaced by Enoxaparin (8000 IU/0.8 ml.), a low molecular weight heparin administered subcutaneously and twice daily. On the third day of this medication, all coagulative measurements returned to normal. PMD disappeared in the second week. Conclusion Low-dose Rivaroxaban 15 mg is not safe for some COVID-19-associated thromboembolism prophylaxis, and careful follow-up is critical due to the possibility of a wide range of pathologic thrombotic manifestations in COVID-19 infection.
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Affiliation(s)
- Murat Tuğrul Eren
- Department of Urology, Acıbadem Healthcare Group, Acibadem Kozyatağı Hospital, 19 Mayıs, Kozyatağı Kavşağı No:24, 34734 Kadıköy/İstanbul, Turkey.,Vocational School of Health Sciences, Head of Surgical Technician Programme, Acıbadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Hakan Özveri
- Department of Urology, Acıbadem Healthcare Group, Acibadem Kozyatağı Hospital, 19 Mayıs, Kozyatağı Kavşağı No:24, 34734 Kadıköy/İstanbul, Turkey.,Department of Urology, School of Medicine, Acıbadem Mehmet Ali Aydinlar University, Ondokuz Mayıs Mah. Begonya Sk. No: 12, Kadıköy/İstanbul, Turkey
| | - Hilal Kurtoğlu
- Department of Cardiology, Acıbadem Healthcare Group, Acibadem Hospital, Tekin Sk. No:8, 34718 Kadıköy/İstanbul, Turkey
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29
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Viviano A, Steele D, Edsell M, Jahangiri M. Over-the-counter natural products in cardiac surgery: a case of ginseng-related massive perioperative bleeding. BMJ Case Rep 2017; 2017:bcr-2016-218068. [PMID: 28784871 DOI: 10.1136/bcr-2016-218068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of massive perioperative bleeding due to severe coagulopathy following urgent aortic and mitral valve replacement. Bleeding was persistent despite prolonged and meticulous surgical haemostasis and required high-volume blood products transfusions. No obvious cause was found to justify the severity of the coagulopathy, which was later attributed to high preoperative intake of ginseng.This case highlights the powerful activity of certain over-the-counter remedies on haemostasis, in this particular case on coagulation status. This also reminds us the paramount importance of a sound and comprehensive drug history for surgical patients.
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Affiliation(s)
- Alessandro Viviano
- Department of Cardiothoracic Surgery, St George's University Hospital NHS Foundation Trust, London, UK
| | - Duncan Steele
- Department of Cardiac Surgery, St George's Hospital, London, UK
| | - Mark Edsell
- Department of Cardiac Surgery, St George's Hospital, London, UK
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30
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Cerrud-Rodriguez RC, Quinteros MG, Azam M. Internal carotid artery occlusion and stroke as a complication of cisplatin-based chemotherapy for metastatic testicular germ cell tumour. BMJ Case Rep 2017. [PMID: 28630245 DOI: 10.1136/bcr-2017-220084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Testicular tumours are the most common tumours in young men. Germ cell tumours (GCTs) account for 95% of all testicular cancers, and the non-seminomatous type (NSGCT) accounts for 50% of all GCTs. Cisplatin-based chemotherapy is curative in up to 90% of patients, but it is not without its inherent risks. Ischaemic stroke is a very uncommon, but severe complication of cisplatin-based chemotherapy. Strokes in young patients cause a disproportionately large economic impact by leaving victims disabled during their most productive years and strains the healthcare system with expensive hospital stays. We present a case of a young male patient with past medical history of metastatic NSGCT with the sudden onset of dysarthria, left hemiplegia and ipsilateral hemisensory loss 3 days after receiving cisplatin-based chemotherapy. Subsequent studies revealed a stroke involving the right middle cerebral artery territory secondary to an acute right internal carotid occlusion.
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Affiliation(s)
| | | | - Mohammed Azam
- SBH Health System, Internal Medicine, Bronx, New York, USA
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31
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Abstract
We present the case of 60-year-old man with type 2 diabetes who developed blistering after two sequential exposures to linagliptin. Linagliptin is one of the dipeptidyl peptidase 4 (DPP-4) inhibitors, a group of oral hypoglycaemic agents used commonly for the treatment of type 2 diabetes. On the first exposure to linagliptin, he developed blisters on the hands which resolved after stopping the drug. After repeat exposure, he developed two large blisters on the left foot, which burst giving rise to secondary infection, requiring hospital admission for treatment. We discuss the latest research linking DPP-4 inhibitors with adverse skin reactions and the effect of ulcers on the morbidity and mortality of patients with diabetes. This case report highlights skin reactions as an important, rare and lesser known side effect of DPP-4 inhibitors.
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Affiliation(s)
| | - Naima Shahzad
- Diabetes & Endocrinology Department, Barnet Hospital, Herts, UK
| | - Jonathan Katz
- Diabetes & Endocrinology Department, Barnet Hospital, Herts, UK
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32
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Gandotra SD, Smotrys MA, Patel DB, Chadha A. Systemic inflammatory response syndrome (SIRS) and a left bundle branch block (LBBB) due to nitrofurantoin. BMJ Case Rep 2017; 2017:bcr-2016-218127. [PMID: 28536210 DOI: 10.1136/bcr-2016-218127] [Citation(s) in RCA: 4] [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] [Indexed: 01/22/2023] Open
Abstract
We present a case of a 74-year-old woman, who was on nitrofurantoin treatment for urinary tract infection (UTI), with fever and chills 7 hours after taking nitrofurantoin. She was hospitalised and evaluated for worsening UTI and sepsis. Initially, it appeared to be secondary to post-UTI sepsis because of possible resistant infection or conditions like pulmonary embolism or acute hepatitis. The patient also developed systemic inflammatory response syndrome, left bundle branch block (LBBB), thrombocytopaenia and transaminitis. Considering the side effects of nitrofurantoin, it was stopped. The patient showed improvement and recovered completely with symptomatic and supportive treatment. During follow-up visits with her primary care physician, thrombocytopaenia, transaminitisandLBBB were found to have been resolved.
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Affiliation(s)
| | - Mariola A Smotrys
- Infectious Diseases, Pocono Medical Center, East Stroudsburg, Pennsylvania, USA
| | | | - Akash Chadha
- Infectious Diseases, Pocono Medical Center, East Stroudsburg, Pennsylvania, USA
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Bhattacharya S, Singh A. Why tuberculosis control programmes fail? Role of microlevel and macrolevel factors: an analysis from India. BMJ Case Rep 2017; 2017:bcr-2017-219606. [PMID: 28432172 DOI: 10.1136/bcr-2017-219606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
India accounts for one-fourth of the global tuberculosis (TB) burden. The National TB Program was started in 1962. Over a period of time, some lacunae such as poor case detection rate and incomplete treatment were observed. Later, the government formulated the Revised National Tuberculosis Control Program (RNTCP), which achieved a case detection rate of 70% and a cure rate of 85%. Still, the problem of relapse and defaulter cases persists. In 2014, 6% defaulter cases were reported from India. RNTCP has also focused on microlevel aspects, that is, newer diagnostics such as GenXpert, line probe assay and medicines such as bedaquiline for drug-resistant TB. Action on the macrolevel aspects, for example, social determinants, is ignored. This is natural because these are out of the purview of the health sector. This case study reflects how a resident doctor in a rural clinic of North India tried to resolve the macrolevel and microlevel issues pertaining to defaulter TB cases.
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Affiliation(s)
- Sudip Bhattacharya
- Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amarjeet Singh
- Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
A 74-year-old man undergoing rehabilitation after pneumonia developed right upper quadrant abdominal pain. Five days earlier he had been commenced on apixaban for a new diagnosis of atrial fibrillation. Ultrasound and CT scans revealed an acalculous grossly thickened gallbladder, with high attenuation non-echogenic material both within and surrounding the structure. Active contrast extravasation was seen at the neck. On laparotomy, a perforated internally bleeding gallbladder containing a single calculus was found, with significant free blood within the abdomen. After cholecystectomy, the patient recovered slowly in hospital before nursing home placement.
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Affiliation(s)
- Ned Kinnear
- Department of Urology, Austin Health, Heidelberg, Victoria, Australia .,Department of General Surgery, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - Derek Barry Hennessey
- Department of Urology, Austin Health, Heidelberg, Victoria, Australia.,Department of Urology, Craigavon Area Hospital, Portadown, UK
| | - Rebecca Thomas
- Department of General Surgery, Lyell McEwin Hospital, Elizabeth Vale, Australia
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Hinojosa CA, Lizola R, Laparra-Escareno H, Anaya-Ayala JE. Endovascular recanalisation of a chronic occlusion of the retrohepatic IVC associated to a filter in a patient with antiphospholipid syndrome. BMJ Case Rep 2017; 2017:bcr-2016-218697. [PMID: 28385907 DOI: 10.1136/bcr-2016-218697] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Inferior vena cava (IVC) filters are useful adjuncts to prevent venous thromboembolism to the pulmonary circulation in the setting of contraindication for anticoagulation. Despite their proven decreased rate of pulmonary embolism, IVC filters are not without complications. We herein present the case of a 22-year-old man with a history of antiphospholipid antibody syndrome who was sent to our institution for evaluation with Budd-Chiari and post-thrombotic syndromes associated to a chronic retrohepatic complete IVC occlusion secondary to an IVC filter placed 5 years earlier. Via common femoral, transjugular and transhepatic accesses, we performed a successful endovascular recanalisation and reconstruction of the IVC with a 16 mm×60 mm covered stent; the hepatic outflow was restored with an 8×20 mm Palmaz stent. At 12-month follow-up, his symptoms have resolved, and his liver tests are within normal limits. He remains on systemic anticoagulation.
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Affiliation(s)
- Carlos A Hinojosa
- Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran', Mexico, Mexico
| | - Rene Lizola
- Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran', Mexico, Mexico
| | - Hugo Laparra-Escareno
- Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran', Mexico, Mexico
| | - Javier E Anaya-Ayala
- Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran', Mexico, Mexico
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Hervé F, Viaene A, Everaert K. OnabotulinumtoxinA injections in detrusor facilitate self-catheterisation in a patient with paraplegia and bladder outlet dyssynergia. BMJ Case Rep 2017; 2017:bcr-2016-218429. [PMID: 28389505 DOI: 10.1136/bcr-2016-218429] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case report describes the case of improvement of clean intermittent catheterisation procedures after each intradetrusor administration of onabotulinumtoxinA in a 45-year-old man with L1 paraplegia with neurogenic detrusor overactivity and bladder outlet dyssynergia.On three occasions, improvement on clean intermittent catheterisation procedures appeared 10 to 14 days after intradetrusor injections of onabotulinumtoxinA and lasted for 9 months. We hypothesise a possible influence of intravesical injections of onabotulinumtoxinA on the storage reflex. We also discuss the possibility of a dispersion of onabotulinumtoxinA towards contiguous structures such as the urethral sphincter.
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Affiliation(s)
- François Hervé
- Department of Urology, Universitair Ziekenhuis Gent, Gent, Belgium
| | - Annick Viaene
- Department of Physical Medicine and Orthopedic Surgery, Universitair Ziekenhuis Gent, Gent, Belgium
| | - Karel Everaert
- Department of Urology, Universitair Ziekenhuis Gent, Gent, Belgium
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Cherbanyk F, Gassend JL, Martinet O. Unusual clinical umbilical hernia: pitfall. BMJ Case Rep 2017; 2017:bcr-2016-219039. [PMID: 28381548 DOI: 10.1136/bcr-2016-219039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Floryn Cherbanyk
- Department of Surgery, HFR Fribourg Hôpital Cantonal, Fribourg, Switzerland
| | - Jean-Loup Gassend
- Department of Surgery, HFR Fribourg Hôpital Cantonal, Fribourg, Switzerland
| | - Olivier Martinet
- Department of Surgery, Hôpital Riviera-Chablais, Montreux, Switzerland
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Abstract
The risk of developing pericarditis secondary to Methicillin-Resistant Staphylococcus aureus (MRSA) infection in the absence of preceding surgical procedure is extremely low. We present a case report of a 36-year-old woman who developed disseminated MRSA infection leading to purulent pericarditis.
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Affiliation(s)
- Pradeep Kumar Mada
- Department of Infectious diseases, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Beth Cady
- Department of Infectious diseases, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Anajana De Silva
- Department of Infectious diseases, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Mohammad Alam
- Department of Infectious diseases, Louisiana State University Health Sciences Center, Shreveport, USA
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