1
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Abstract
We present a case of severe rash following induction of elexacaftor, tezacaftor and ivacaftor (ELX/TEZ/IVA) in a young adult male cystic fibrosis patient. While rash is a commonly reported side effect which resolves in 1-2 weeks with minimal intervention, our patient had presented with fever and widespread rash prompting medication cessation. After a washout period, reintroduction with 1/2 tablet of ELX/TEZ/IVA produced a similar systemic response within 24 hours. Repeat attempt, this time with 1/8 tablet and increasing in increments of an eighth daily, was successful and has allowed our patient to experience the transformative benefits of ELX/TEZ/IVA including improved pulmonary function and reduced episodes of infective exacerbation. This case illustrates one of the most common side effects of ELX/TEZ/IVA triple therapy, and our experience of desensitisation to ELX/TEZ/IVA in a challenging case of rash.
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Affiliation(s)
- Ann Cheng
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK
| | - Olivia Baker
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK
| | - Uta Hill
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK
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2
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Sofia C, Simonetti J, Boccabella C, Bonini M. When one plus one means more than two: the blockade of both IL-4 and IL-13 inflammatory pathways with dupilumab in a case of severe refractory T2-high asthma. BMJ Case Rep 2022; 15:e244503. [PMID: 35039340 PMCID: PMC8767963 DOI: 10.1136/bcr-2021-244503] [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: 12/05/2021] [Indexed: 11/04/2022] Open
Abstract
Novel approach of asthma includes personalised therapy involving specific immune pathways. We describe here a case of T2-high asthma in a 66-year-old woman treated with maximal inhaled therapy and inappropriate usage of oral corticosteroids showing poor symptoms control. Both anti-IgE and (omalizumab) and anti-interleukin (IL)-5 (mepolizumab) monoclonal antibodies treatments were prescribed without significant benefit. Add-on subcutaneous dupilumab, a monoclonal antibody directed against the IL-4 receptor subunit alpha, inhibiting signalling from both IL-4 and IL-13, proved to be an effective and safe medication to obtain rapid asthma control. Considering the previous lack of response to both anti-IgE and anti-eosinophilic strategies, we hypothesise that dupilumab upstream activity could exert different and more relevant effects than the simple inhibition of the two single downstream pathways. The current case highlights the need for a deeper analysis of biomolecular interactions in the framework of different asthma endotypes, to identify peculiar profiles associated with specific treatment responses.
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Affiliation(s)
- Carmelo Sofia
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Lazio, Italy
| | - Jacopo Simonetti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Lazio, Italy
| | - Cristina Boccabella
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Lazio, Italy
| | - Matteo Bonini
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Lazio, Italy
- National Heart and Lung Institute (NHLI), Imperial College London, London, UK
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3
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Abstract
A 57-year-old man with acute promyelocytic leukaemia (APML) received induction therapy including all-trans-retinoic acid (ATRA). At day 15, he developed dyspnoea, haemoptysis and hypoxia. Thorax CT demonstrated diffuse ground-glass opacity and consolidation predominantly in dorsal regions, which may reflect increased vascular permeability. He was diagnosed with differentiation syndrome. After dexamethasone was administered and chemotherapy suspended, his symptoms improved and abnormal lesions mostly disappeared on follow-up CT examinations. We report a short-term high-resolution CT series of differentiation syndrome.
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Affiliation(s)
- Tatsuya Oki
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yukihiro Nagatani
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Wataru Saika
- Department of Haematology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yoshiyuki Watanabe
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
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4
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Ban AYL, Ng BH, Faisal M, Rajah R. Single dose of rituximab causing organising pneumonia in a patient with B-cell lymphoproliferative disorder. BMJ Case Rep 2021; 14:e245837. [PMID: 34711625 PMCID: PMC8557278 DOI: 10.1136/bcr-2021-245837] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/03/2022] Open
Abstract
Rituximab (RTX) is a monoclonal anti-CD20 antibody used to treat non-Hodgkin's lymphoma. RTX-organising pneumonia (RTX-OP) is a rare complication following treatment with RTX. We report a 49-year-old woman, with CD5-negative B-cell lymphoproliferative disorder who developed high-grade fever, dyspnoea and dry cough 3 days after the first dose of RTX. She responded poorly to antibiotics and antifungal therapy. High-resolution CT (HRCT) of the chest revealed bilateral patchy ground-glass opacities with arcade-like signs suggestive of OP. She was pulsed with intravenous methylprednisolone and RTX was discontinued. She was able to be weaned off the non-invasive ventilation (NIV) support and was discharged with maintenance prednisolone 1 mg/kg and tapered over 6 weeks. A repeated HRCT of the chest at 6 weeks showed a total resolution of OP. This highlights the early occurrence at day 3 of RTX-OP following the first dose of RTX and the complete resolution with steroid therapy.
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Affiliation(s)
- Andrea Yu-Lin Ban
- Respiratory Unit, Department of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Boon Hau Ng
- Respiratory Unit, Department of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohamed Faisal
- Respiratory Unit, Department of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Rathika Rajah
- Respiratory Unit, Department of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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5
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Abstract
A 70-year-old man was referred to our respiratory department with non-productive cough over the past 6 months. High-resolution CT revealed reticular pattern with basal and peripheral predominance, centrilobular nodules and mild ground glass opacities. Serology tests were normal and bronchoalveolar lavage revealed lymphocytosis. Pulmonary function tests showed functional impairment and reduced diffusing capacity for carbon monoxide. Meticulous evaluation of patient's medical history unveiled longitudinal administration of infliximab due to diagnosis of psoriasis. The working diagnosis of drug-induced interstitial lung disease was proposed following multidisciplinary discussion. Considerable radiological and functional improvement was determined 6 months following infliximab discontinuation without implementation of corticosteroids. To this end, the patient has reported remission of cough and functional improvement.
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Affiliation(s)
| | - Ourania Papaioannou
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
| | - Fotios Sampsonas
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
| | - Argyrios Tzouvelekis
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
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6
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Abstract
Diffuse alveolar haemorrhage (DAH) has been reported as a rare complication of clopidogrel use and is usually a diagnosis of exclusion. We describe the case of an 88-year-old Native American woman who presented with acute hypoxic respiratory failure with CT scan of the chest showing diffuse bilateral ground-glass opacities. She had been on clopidogrel for 6 months for a carotid artery stent. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsies revealed DAH. Infectious and autoimmune work-up were all negative. Clopidogrel was stopped and high-dose steroids were started. Her symptoms gradually improved until she was discharged from the hospital. The differential DAH is broad. Anticoagulant-induced DAH should be part of the differential diagnosis, and is usually a diagnosis of exclusion.
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Affiliation(s)
- Rachelle Soriano
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Saud Al-Rawaf
- Division of Pulmonary, Critical Care, and Sleep Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Khalil Diab
- Division of Pulmonary, Critical Care, and Sleep Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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7
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Rabascall CX, Lou BX, Navetta-Modrov B, Hahn SS. Effective use of monoclonal antibodies for treatment of persistent COVID-19 infection in a patient on rituximab. BMJ Case Rep 2021; 14:e243469. [PMID: 34344651 PMCID: PMC8336168 DOI: 10.1136/bcr-2021-243469] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 11/24/2022] Open
Abstract
As we are over a year into the COVID-19 pandemic, we have made many forward strides in therapeutics. These treatments, such as monoclonal antibodies, have help mitigate the detrimental and often fatal consequences of COVID-19. The current indication for the use of monoclonal antibodies is mild to moderate COVID-19 infection within 10 days of symptom onset in those who are at high risk of progression to severe disease. However, their role in patients with prolonged symptoms is not clear. We present a unique case of monoclonal antibodies use after 54 days of symptom onset in an immunosuppressed patient with persistent COVID-19 infection despite standard treatment. This case illustrates the potential use of monoclonal antibodies outside of the current recommended therapeutic window in immunosuppressed patients, who may have difficulty with viral clearance.
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Affiliation(s)
- Carlos X Rabascall
- Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, New York, USA
| | - Becky X Lou
- Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, New York, USA
| | - Brianne Navetta-Modrov
- Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Stella S Hahn
- Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, New York, USA
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8
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Abstract
Omalizumab is an anti-IgE monoclonal antibody used in severe allergic asthma. Herein, we describe a case of eosinophilic granulomatosis with polyangiitis, which manifested 3 months after initiation of omalizumab therapy, while maintenance corticosteroid therapy dose was unchanged.
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Affiliation(s)
- Luke Nessan Carson
- Respiratory Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Ashish Pradhan
- Respiratory Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Deepak Subramanian
- Respiratory Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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9
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Abstract
Severe asthma is very difficult to manage in many individuals, and systemic corticosteroids are often used to prevent or manage acute exacerbations. Furthermore, comorbid allergic conditions may render standard therapies inadequate. A 51-year-old man presented with severe eosinophilic asthma requiring nearly constant oral corticosteroid usage despite using high-dose inhaled corticosteroids and secondary asthma controllers. His condition was complicated by aspirin-exacerbated respiratory disease, including severe nasal polyposis, chronic rhinosinusitis, as well as chronic idiopathic urticaria. Mepolizumab was initiated and led to dramatic improvement of asthma over 6 months. However, he continued to experience exacerbations of chronic idiopathic urticaria not responsive to H1-antihistamines. Omalizumab was added, and the patient's urticaria attained marked improvement with only an occasional breakthrough rash. Dual biologic therapies can be a unique and useful steroid-sparing treatment option for patients with uncontrolled severe asthma and chronic idiopathic urticaria.
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Affiliation(s)
- Joshua Ray Caskey
- Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - David Kaufman
- Section of Allergy/Immunology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
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10
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Mata L, Torres-Zevallos H, Guerreros AG. Life-threatening DRESS syndrome with kidney damage following severe COVID-19 in a patient with Down syndrome. BMJ Case Rep 2021; 14:14/4/e241418. [PMID: 33875507 PMCID: PMC8057573 DOI: 10.1136/bcr-2020-241418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Lorena Mata
- Department of Research and Education, Clinica Internacional SA, Lima, Peru
| | - Hernando Torres-Zevallos
- Department of Research and Education, Clinica Internacional SA, Lima, Peru.,Department of Pulmonology, Clinica Internacional SA, Lima, Peru
| | - Alfredo Gilberto Guerreros
- Department of Research and Education, Clinica Internacional SA, Lima, Peru .,Department of Pulmonology, Clinica Internacional SA, Lima, Peru
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11
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Abstract
A severe case of COVID-19 was observed in an otherwise healthy 28-year-old man who had taken oxandrolone 40 mg/day as an anabolic steroid. The patient had been taking oxandrolone for enhanced bodybuilding 30 days prior to presenting to an outpatient clinic with COVID-19 symptoms. The patient reported that his symptoms have rapidly worsened over the course of 4 days prior to presenting at the clinic. As part of an experimental antiandrogen treatment for hyperandrogenic men suffering from COVID-19, he was administered a single 600 mg dose of the novel antiandrogen proxalutamide. Twenty-four hours after administration of this dose, marked improvement of symptoms and markers of disease severity were observed. To our knowledge, this is the first case that potentially links anabolic steroid use to COVID-19 disease severity.
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Affiliation(s)
- Flavio Cadegiani
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/UNIFESP), São Paulo, São Paulo, Brazil
- Corpometria Institute, Brasilia, Distrito Federal, Brazil
| | - Erica M Lin
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Andy Goren
- Applied Biology Inc, Irvine, California, USA
| | - Carlos G Wambier
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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12
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Li A, Mohammadi F, Crocker H. Bilateral temporomandibular joint dislocations post-bronchoscopy in a case of paclitaxel-induced pneumonitis. BMJ Case Rep 2021; 14:14/2/e240146. [PMID: 33619143 PMCID: PMC7903068 DOI: 10.1136/bcr-2020-240146] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This case report presents the unusual complication of bilateral temporomandibular joint dislocation following bronchoscopy, highlighting the importance of recognising it as a differential diagnosis in patients having jaw symptoms. The delayed diagnosis in this case resulted in multiple unsuccessful reduction attempts under sedation, which added to the distress of the patient. Notably, the procedure yielded a rare diagnosis for the patient that intrinsically changed the management of her breast cancer.
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Affiliation(s)
- Anna Li
- Respiratory, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Fadak Mohammadi
- Respiratory, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Helen Crocker
- Respiratory, Flinders Medical Centre, Bedford Park, South Australia, Australia
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13
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Ng BH, Mohd Aminudin NH, Nasaruddin MZ, Abdul Rahaman JA. Successful drainage of complex haemoserous malignant pleural effusion with a single modified low-dose intrapleural alteplase and dornase alfa. BMJ Case Rep 2021; 14:14/2/e239702. [PMID: 33547099 PMCID: PMC7871233 DOI: 10.1136/bcr-2020-239702] [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: 02/06/2023] Open
Abstract
Patients with symptomatic complex malignant pleural effusion (MPE) are frequently unfit for decortication and have a poorer prognosis. Septations can develop in MPE, which may lead to failure of complete drainage and pleural infection. Intrapleural fibrinolytic therapy (IPFT) is an alternative treatment. The use of IPFT in patients with anaemia and high risk for intrapleural bleeding is not well established. We report a successful drainage of complex haemoserous MPE with a single modified low-dose of intrapleural 5 mg of alteplase and 5 mg of dornase alfa in a patient with pre-existing anaemia with no significant risk of intrapleural bleeding.
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Affiliation(s)
- Boon Hau Ng
- Medical Department, Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Wilayah Persekutuan Kuala Lumpur, Malaysia
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14
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Odish MF, McGuire WC, Thistlethwaite P, Crotty Alexander LE. Bleomycin-induced lung injury treated with venovenous extracorporeal membrane oxygenation (ECMO) and ultra-protective ventilator settings. BMJ Case Rep 2020; 13:e236474. [PMID: 33229479 PMCID: PMC7684647 DOI: 10.1136/bcr-2020-236474] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 11/03/2022] Open
Abstract
Bleomycin treats malignancies, such as germ cell tumours and Hodgkin lymphoma. While efficacious, it can cause severe drug-induced lung injury. We present a 42-year-old patient with stage IIB seminoma treated with radical orchiectomy followed by adjuvant chemotherapy with bleomycin, etoposide and cisplatin. His postbleomycin course was complicated by the rapid onset of hypoxic respiratory failure, progressing to acute respiratory distress syndrome and requiring venovenous extracorporeal membrane oxygenation (VV-ECMO) support. Although the patient was treated with high dose systemic steroids and ultra-protective ventilator strategies to minimise ventilator-induced lung injury while on VV-ECMO, his lung injury failed to improve. Care was withdrawn 29 days later. Lung autopsy revealed diffuse organising pneumonia. We found six case reports (including this one) of bleomycin-induced lung injury requiring VV-ECMO with a cumulative survival of 33% (2/6). While VV-ECMO may be used to bridge patients to recovery or lung transplant, the mortality is high.
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Affiliation(s)
- Mazen Faris Odish
- Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - William Cameron McGuire
- Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Patricia Thistlethwaite
- Surgery, Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California, USA
| | - Laura E Crotty Alexander
- Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, USA
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15
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Harlow CF, Meghji J, Martin L, Harris T, Kon OM. Republished: Rifampicin induced shock during re-exposure for treatment of latent tuberculosis. Drug Ther Bull 2020; 58:157-159. [PMID: 32563996 DOI: 10.1136/dtb.2020.232117rep] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Jamilah Meghji
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Laura Martin
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Timothy Harris
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Onn Min Kon
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
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16
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Marinelli L, Ristagno E, Fischer P, Abraham R, Joshi A. Cryptococcal pneumonia in an adolescent with a gain-of-function variant in signal transduction and activator of transcription 1 ( STAT1). BMJ Case Rep 2020; 13:13/4/e234120. [PMID: 32327459 DOI: 10.1136/bcr-2019-234120] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
An adolescent male with a history of autoimmune enteropathy, autoimmune hypothyroidism, aphthous stomatitis and recurrent oral Candida infections only in the setting of curative antibiotic courses presented with cryptococcal pneumonia and perihilar adenitis, which was successfully treated with antifungal therapy. The patient had a complex history with several immunological anomalies. Whole exome sequencing revealed a known STAT1 pathogenic variant, associated with gain of function (GOF). This case expands our understanding of the broad clinical phenotype manifested by STAT1 GOF and emphasises the importance of consideration of this diagnosis in patients presenting with opportunistic infections and autoimmunity.
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Affiliation(s)
- Lisa Marinelli
- Department of Pathology, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
| | - Elizabeth Ristagno
- Department of Pediatric and Adolescent Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Philip Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Roshini Abraham
- Department of Pathology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Avni Joshi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
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17
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Nixon R, Despiney R, Pfeffer P. Case of paradoxical adverse response to mepolizumab with mepolizumab-induced alopecia in severe eosinophilic asthma. BMJ Case Rep 2020; 13:13/2/e233161. [PMID: 32086326 DOI: 10.1136/bcr-2019-233161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Recent years have seen an increase in use of mepolizumab and other biological therapies for the treatment of severe eosinophilic asthma. A few cases of paradoxical responses to mepolizumab therapy have now been reported and are hypothesised as being a response to immune complex formation. We present a case of mepolizumab-induced alopecia in a patient with paradoxical adverse response to mepolizumab given for severe eosinophilic asthma. We postulate this could be secondary to autoimmune mechanisms and that it could help herald poor response to treatment, thereby facilitating early identification of patients having paradoxical responses.
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Affiliation(s)
| | | | - Paul Pfeffer
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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18
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Harlow CF, Meghji J, Martin L, Harris T, Kon OM. Rifampicin induced shock during re-exposure for treatment of latent tuberculosis. BMJ Case Rep 2020; 13:e232117. [PMID: 32014989 PMCID: PMC7021163 DOI: 10.1136/bcr-2019-232117] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2020] [Indexed: 11/03/2022] Open
Abstract
We present a case of a young Asian female with rheumatoid arthritis who received latent tuberculosis infection (LTBI) treatment prior to treatment with a biologic agent, and developed shock with resistant hypotension on re-exposure to rifampicin. We discuss the epidemiology, pathophysiology and management of rifampicin induced shock, concluding that clinicians should be aware of this rare, but potential adverse effect, and be aware that adverse reactions to rifampicin are more frequent during re-exposure or longer dosing interval regimes. The evidence for desensitisation following such a reaction is lacking and this approach is not currently recommended. We would suggest close collaboration between specialties prescribing immunosuppression and the tuberculosis team when LTBI treatment is required after a reaction, with patient involvement to discuss the risks and benefits of treatment options.
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Affiliation(s)
| | - Jamilah Meghji
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Laura Martin
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Timothy Harris
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Onn Min Kon
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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19
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Abstract
We report the case of a 43-year-old African American man with a history of hypertension and chronic kidney disease presenting with hypertensive emergency and bulbar paralysis in a descending fashion, which ultimately led to acute respiratory failure. He ingested pufferfish liver during the preceding 4 hours prior to presentation, as well as canned foods and cocaine over the prior 3 days. He had a complicated hospital course requiring intubation and mechanical ventilation, as well as the development of acute respiratory distress syndrome and acute renal failure requiring haemodialysis. This case exemplifies the classic manifestations of tetrodotoxin poisoning with some unique overlapping features, in the setting of an interesting social history.
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Affiliation(s)
- Patricia Almeida
- Pulmonary Medicine, Aventura Hospital and Medical Center, Aventura, Florida, USA
| | - Raiko Diaz
- Pulmonary Medicine, Aventura Hospital and Medical Center, Aventura, Florida, USA
| | - Felix Hernandez
- Pulmonary Medicine, Aventura Hospital and Medical Center, Aventura, Florida, USA
| | - Gustavo Ferrer
- Pulmonary Medicine, Aventura Hospital and Medical Center, Aventura, Florida, USA
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20
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Abstract
General lymphatic anomaly (GLA) is a very rare disorder, characterised by multifocal lymphatic malformations into various tissues that is due to congenital abnormalities of lymphatic development. No treatment has ever proved its efficiency.We report a 22-year-old man with recurrent bronchial casts due to thoracic involvement of GLA. After a 6-month treatment with sildenafil (20 mg three times a day), a phosphodiesterase 5 inhibitor, chest CT scan showed a complete regression of ground-glass opacities and lung function test results improved substantially and remained stable for 1 year. The treatment was well tolerated.This observation suggests that sildenafil may be a therapeutic approach to be tested in thoracic involvement of GLA.
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Affiliation(s)
- Arnaud Maurac
- Centre Hospitalier Universitaire de Nancy, Département de pneumologie, CHRU de Nancy, Vandoeuvre-lès-Nancy, France
| | - Marie-Pierre Debray
- Service de Radiologie, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Bruno Crestani
- Service de Pneumologie et Centre de Référence Constitutif des Maladies Pulmonaires Rares, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris, Paris, France.,Département Hospitalo-Universitaire FIRE; INSERM UMR 1152; LabEx Inflamex, Université Paris Diderot, UFR de Médecine Site Xavier-Bichat, Paris, France
| | - Camille Taillé
- Service de Pneumologie et Centre de Référence Constitutif des Maladies Pulmonaires Rares, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris, Paris, France.,Département Hospitalo-Universitaire FIRE; INSERM UMR 1152; LabEx Inflamex, Université Paris Diderot, UFR de Médecine Site Xavier-Bichat, Paris, France
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Wu JH, Jerng JS, Su CC. Insidious-onset, non-wheezing carteolol-induced asthma in an atopic patient without asthma history. BMJ Case Rep 2019; 12:12/4/e229343. [PMID: 30948417 DOI: 10.1136/bcr-2019-229343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Carteolol, a non-selective beta-antagonist with a potential risk of severe bronchial constriction in patients with asthma, is one of the most commonly prescribed medication for managing ocular pressure in glaucoma. We present a case of a 24-year-old woman with a history of atopy but no known asthma who presented an insidious onset of clinical manifestations compatible with drug-induced asthma after the initiation of carteolol for ocular hypertension control. The patient developed progressive chest tightness and dyspnoea for 2 months before the pulmonary function test revealed a positive bronchoprovocation response. She reported significant improvement of respiratory symptoms within 2 weeks after the discontinuation of carteolol, and a negative provocation response was later confirmed by repeat pulmonary function test. In conclusion, eye drops with non-selective beta-antagonising effect can induce asthmatic symptoms in patients without a previous diagnosis of asthma and should be administered with caution in patients with associated risk factors.
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Affiliation(s)
- Jo-Hsuan Wu
- National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chia Su
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
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22
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O'Callaghan M, Fabre A, Keane M, McDonnell TJ. 'When you hear hooves, think zebras, not horses'; two challenging cases of interstitial lung disease (ILD). BMJ Case Rep 2019; 12:12/2/bcr-2018-224507. [PMID: 30755425 DOI: 10.1136/bcr-2018-224507] [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
Our case series describes two siblings with complex fibrosing lung diseases. The first patient was initially given a diagnosis of sarcoidosis based on imaging and exclusion of alternative diagnoses. A number of years after diagnosis, he had rapid deterioration of his disease and following surgical lung biopsy, his lung fibrosis was re-classified as chronic hypersensitivity pneumonitis (cHP) with a usual interstitial pneumonia pattern. He subsequently underwent successful lung transplantation. The second patient presented with rapidly progressing exertional dyspnoea. His bloods, imaging, bronchoalveolar lavage and histology were discussed at our multidisciplinary team meeting. His histology was most in keeping with subacute on cHP with overlapping imaging features between the two siblings. He was treated accordingly but unfortunately succumbed to his illness shortly after diagnosis. These cases highlight the difficulties differentiating between the various interstitial lung disease (ILD) subtypes and the challenges in management while also increasing awareness of familial ILD.
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Affiliation(s)
- Marissa O'Callaghan
- Department of Respiratory Medicine, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Aurelie Fabre
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Histopathology, St Vincent's University Hospital, Dublin, Ireland
| | - Michael Keane
- Department of Respiratory Medicine, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Timothy J McDonnell
- Department of Respiratory Medicine, St Vincent's University Hospital, Dublin, Ireland
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23
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Abstract
We describe three cases of pulmonary aspergillosis (PA) in three patients without traditional risk factors for invasive aspergillosis infection, such as prolonged neutropenia or high dose systemic corticosteroid therapy. All three patients developed PA while taking tyrosine kinase inhibitors (TKI) and sustained greater clinical improvement once TKI were withdrawn. Our case series supports the theory TKI treatment can increase susceptibility to PA without causing neutropenia. Recognition that TKI treatment may predispose to invasive aspergillosis will allow for rapid recognition of affected patients and more effective management of future cases.
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Affiliation(s)
- Tajwar Nasir
- Respiratory Division of Medicine, University College London Medical School, London, UK
| | - Claudia Lee
- Respiratory Division of Medicine, University College London Medical School, London, UK
| | | | - Jeremy S Brown
- Respiratory Division of Medicine, University College London, London, UK
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24
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Chuah CS, Noble C, Leitch A. Case of steroid-resistant Crohn's-associated bronchiolitis in the setting of quiescent gastrointestinal disease treated with infliximab. BMJ Case Rep 2018; 11:11/1/e226934. [PMID: 30567117 PMCID: PMC6301768 DOI: 10.1136/bcr-2018-226934] [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: 12/17/2022] Open
Abstract
A fit, 36-year-old man with a history of Crohn's disease previously treated with azathioprine, presented acutely with progressive shortness of breath on exertion and pleuritic chest pain. At the time of presentation, his Crohn's disease was quiescent, supported by a normal faecal calprotectin. The initial chest CT suggested the presence of a diffuse inflammatory disorder and he was subsequently started on high dose oral steroids. Despite 4 months of steroid therapy, there was minimal improvement. Following discussion at the inflammatory bowel disease multidisciplinary team meeting, a decision was made to commence infliximab. Subsequently, he made a dramatic clinical and physiological recovery. His forced expiratory volume in 1 s improved from 2.22 L/min (50% predicted) to 3.65 L/min (93% predicted) and he returned to baseline levels of exercise.
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Affiliation(s)
- Cher Shiong Chuah
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
| | - Colin Noble
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
| | - Andrew Leitch
- Department of Respiratory Medicine, Western General Hospital, Edinburgh, UK
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25
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Philip KEJ, Kon OM, Roddie M, Ross C. Pleural tuberculosis: a key differential diagnosis for pleural thickening, even without obvious risk factors for tuberculosis in a low incidence setting. BMJ Case Rep 2018; 2018:bcr-2018-224992. [PMID: 30368474 DOI: 10.1136/bcr-2018-224992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 12/25/2022] Open
Abstract
We report the case of a 64-year-old woman, presenting with pleuritic chest pain and weight loss. She had a previous history of breast malignancy and no clear risk factors for tuberculosis (TB). Initial investigations showed a right-sided pleural effusion and pleural thickening suggestive of malignancy, which would have been in keeping with the clinical presentation. Initial pleural biopsy showed features suggestive of possible TB infection, though no growth on cultures. A repeat biopsy was negative on initial microscopy, but was culture positive for Mycobacterium tuberculosis, also identifying isoniazid resistance. This case highlights that TB remains an important differential even in the absence of classical risk factors, and illustrates the diagnostic challenges it poses. It also highlights the value of culture positivity in identification of drug resistance and facilitation of appropriate treatment.
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Affiliation(s)
| | - Onn Min Kon
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Mary Roddie
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Clare Ross
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
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26
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Abstract
We report a rare case of drug-induced intestinal lung disease (ILD) secondary to adalimumab, a tumour necrosis factor alpha-receptor blocker. A 52-year-old smoker with ankylosing spondylitis, treated with adalimumab, presented with progressive breathlessness. A high resolution CT chest demonstrated predominantly upper-zone patchy ground glass changes and small bilateral pleural effusions. Bronchoscopy and bronchoalveolar lavage showed no evidence of infection or malignant cells and an echocardiogram was normal. The working diagnosis was that of possible adalimumab-induced ILD. Adalimumab was subsequently stopped. The patient's breathlessness and cough improved on cessation of the drug. A further CT chest several months later showed resolution of the ground glass changes. Adalimumab-induced ILD is rare. We review the literature surrounding this and discuss the diagnostic challenges. This case highlights the importance of considering the possibility of drug-induced lung disease in patients taking adalimumab.
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Affiliation(s)
- Seema Alaee
- Department of Respiratory Medicine, Great Western Hospital, Swindon, UK
| | - Quentin Jones
- Department of Respiratory Medicine, Great Western Hospital, Swindon, UK
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27
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Abstract
A 70-year-old man presented with breathlessness, cough and fever while receiving pembrolizumab for melanoma. A CT pulmonary angiogram demonstrated small bilateral upper lobe segmental pulmonary emboli with patchy ground-glass opacities and basal perilobular consolidation, in keeping with organising pneumonia. He was treated for community-acquired pneumonia and pulmonary emboli but rapidly deteriorated, with increasing hypoxia and dyspnoea. He was admitted to the intensive care unit for support with continuous positive airway pressure and high flow nasal oxygen. His clinical condition improved once he received high-dose intravenous methylprednisolone to treat pneumonitis. His treatment was continued with a weaning course of high-dose oral steroids, and he was discharged with a persistent oxygen requirement. The patient maintained a requirement for high doses of oral steroids and continued to deteriorate. He was referred to palliative care for symptom management and died a month following hospital discharge, as a result of pneumonitis due to pembrolizumab.
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Affiliation(s)
- Frances Rickard
- Department of Respiratory Medicine, Bristol Royal Infirmary, Bristol, UK
| | - Catherine Hyams
- Department of Respiratory Medicine, Bristol Royal Infirmary, Bristol, UK
| | - Andrew T Low
- Department of Respiratory Medicine, Bristol Royal Infirmary, Bristol, UK
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