Acute endocarditis complicated by left ventricular pseudoaneurysm with acute bloody pericardial effusion: A case report

RATIONALE

Delay in seeking medical attention for high fever and inadequate diagnosis can lead to rapid progression of inflammation and spread to surrounding tissues and organs. Staphylococcus aureus is a common cause of systemic infections, and infectious endocarditis can swiftly become severe; therefore, careful management is required.

PATIENT CONCERNS

A 54-year-old woman was admitted to our hospital with high fever and progressive loss of consciousness. Meningitis was suspected, and antibiotic treatment was initiated. Blood culture revealed methicillin-sensitive Staphylococcus aureus. Subsequently, the patient developed hypotension, bradycardia, and cardiac arrest and underwent emergency cardiopulmonary resuscitation.

DIAGNOSES

Transesophageal echocardiography performed during the procedure revealed significant vegetation at the posterior leaflet of the mitral valve, an abscess at the valve annulus, and a pseudoaneurysm of the left ventricular posterior wall.

INTERVENTIONS

The patient underwent emergency small incision pericardiotomy drainage, and her blood pressure and heart rate stabilized. After pericardial drainage, acute renal failure, fulminant hepatitis, and disruption of coagulation function were observed, and she was treated with plasma exchange therapy and intravenous immunoglobulin. Resection of the huge vegetation, debridement, patch closure of the ventricular perforation, and mitral valve replacement were performed.

OUTCOMES

Surgical findings showed massive vegetation in the posterior leaflet of the mitral valve, an annular abscess in the posterior leaflet of the mitral valve connected to the left ventricular posterior wall, and a pseudoaneurysm. Postoperatively, her pseudoaneurysm resolved and her cardiac function stabilized, while circulatory failure due to bacteremia progressed, and she gradually developed acidosis and unstable blood pressure. Plasma exchange and continuous hemodiafiltration were continued; however, she died of progressive multiorgan failure.

LESSON

Staphylococcus aureus bacteremia can cause fatal complications. Even when symptoms of meningitis are suspected, it is essential to examine the patient for endocarditis. Delayed diagnosis can lead to fatal endocarditis-related complications.

Skin Rash as a Side Effect of Bortezomib: A Case Report

Bortezomib is a novel proteasome inhibitor widely used in the treatment of multiple myeloma, especially in the case of recurrent, relapsing, or refractory myeloma. Its common side effects include nausea, vomiting, neuropathic pain, and hemorrhage. Cutaneous manifestations are considered rare. Here we report a case of a 72-year-old female patient, and a known case of multiple myeloma on VRD protocol (bortezomib [Velcade] combined with lenalidominde [Revlimid] and dexamethasone) after relapse. The patient presented with a complaint of raised, itchy, erythematous skin rash, starting in the soles and palms and then spreading to the whole body. A skin biopsy confirmed that the lesions were due to an allergic reaction. The patient was admitted as a case of sepsis and died. Skin rash is considered a rare side effect of bortezomib, with variable presentation and onset. The mainstay of treatment is corticosteroids.

Psoriasis Flare-Up in a Patient Treated With Docetaxel for Metastatic Prostate Cancer

Dermatologic toxicities, such as urticaria and mucositis, with docetaxel, have been commonly reported; however, fixed-plaque erythrodysesthesia is a rare adverse phenomenon with a reported incidence of less than 5% of patients. Docetaxel-induced psoriasis is extremely rare, and to date, very few cases have been reported in the literature. We present a literature review of psoriasis cases secondary to docetaxel and report our own case of severe docetaxel-induced psoriasis in the setting of treatment of metastatic prostate cancer. Our patient received topical steroids and narrow-band ultraviolet B (NBUVB) light therapy with resolution of their psoriasis and was able to complete their chemotherapy without discontinuation or interruption of their docetaxel.

A systematic review and clinical atlas on mucocutaneous presentations of the current monkeypox outbreak: With a comprehensive approach to all dermatologic and nondermatologic aspects of the new and previous monkeypox outbreaks

Monkeypox is a zoonotic disease, endemic in central and west African regions, and has re-emerged, currently causing an outbreak as of May 2022. In this systematic review, we aimed to characterize the current face of the disease, with a detailed categorization of mucocutaneous, as well as systemic symptoms of the disease. We searched four main online databases with the keywords "monkeypox" and "Orthopoxvirus". A total of 46 articles were included, with a cumulative number of 1984 confirmed cases. Patients were predominantly men who have sex with men, who were mostly in their 30s, with a history of unprotected sexual contact or international travel. Among mucocutaneous manifestations, anogenital lesions were the most commonly observed, followed by lesions on the limbs, face, trunk, and palms or soles. Among lesion types, vesiculopustular, pustular or pseudo-pustular, vesicular-umbilicated and papular lesions were the most common, mainly presenting asynchronously, with less than 10 lesions on each patient. Almost all patients also reported systemic manifestations, namely fever, lymphadenopathy, fatigue, myalgia, headaches, pharyngitis, and proctitis. Sexual contact is the main pathway of transmission in the current outbreak, with viral shedding in bodily fluids playing a key role. We've compared these idiosyncratic findings of the new outbreak with previous outbreaks. We've also gathered and categorized images from our included studies to make a "clinical atlas" for this "new" face of monkeypox, which can be of utmost importance for clinicians to be familiarized with, and have a clear picture of monkeypox for their differential diagnoses.

Initiation Dose of Allopurinol and the Risk of Severe Cutaneous Reactions in Older Adults With CKD: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

Allopurinol should be started at lower doses in patients with chronic kidney disease (CKD) to avoid adverse effects. We examined the risk of severe cutaneous reactions in older adults with CKD who were newly prescribed allopurinol at varied doses.

STUDY DESIGN

Population-based cohort study using linked health care databases.

SETTING & PARTICIPANTS

Patients in Ontario, Canada (2008-2019) aged ≥66 years, with an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m², and who were new users of allopurinol.

EXPOSURE

A new prescription for allopurinol >100 mg/d versus a dose ≤100 mg/d.

OUTCOME

The primary outcome was a hospital visit with a severe cutaneous reaction within 180 days of starting allopurinol. Secondary outcomes included all-cause hospitalization and all-cause mortality.

ANALYTICAL APPROACH

The exposure and referent groups were balanced on indicators of baseline health using inverse probability of treatment weighting on the propensity score. Weighted risk ratios (RR) were obtained using modified Poisson regression and weighted risk differences (RD) using binomial regression.

RESULTS

Of 47,315 patients (median age, 76 years; median eGFR, 45 mL/min/1.73 m²), 55% started allopurinol at >100 mg/d. Starting allopurinol at >100 versus ≤100 mg/d was associated with an increased risk of a severe cutaneous reaction: number of events (weighted), 103 of 25,802 (0.40%) versus 46 of 25,816 (0.18%), respectively (weighted RR, 2.25 [95% CI, 1.50-3.37]; weighted RD, 0.22% [95% CI, 0.12%-0.32%]. Starting allopurinol at >100 versus ≤100 mg/d was associated with an increased risk of all-cause hospitalization but not with all-cause mortality.

LIMITATIONS

This study was underpowered to detect risk differences in the association of allopurinol dose with outcomes across eGFR categories (ie, 45-59, 30-44, and <30 mL/min/1.73 m²).

CONCLUSIONS

Older patients with CKD who started allopurinol at >100 mg/d versus ≤100 mg/d were twice as likely to visit a hospital with a severe cutaneous reaction in the next 180 days.

Clinical approach to skin eruptions induced by anti-TNF agents among patients with inflammatory bowel diseases: insights from a multidisciplinary IBD-DERMA clinic

BACKGROUND AND AIMS

Skin eruptions are prevalent among patients with inflammatory bowel diseases (IBD), often associated with therapies and frequently leading to dermatological consults and treatment interruptions. We aimed to assess the impact of joint shared decision-making in a multidisciplinary (MDT) IBD-DERMA clinic.

METHODS

This retrospective cohort study assessed a consecutive group of patients with IBD who were referred for consultation in an MDT clinic at a tertiary referral center in Israel.

RESULTS

Over 1 year, 118 patients were evaluated in the MDT-IBD-DERMA clinic: 68 (57.6%) males; age - 35.2 ± 13.5 years, disease duration - 7.1 (interquartile range: 3.7-13.9) years; Crohn's disease - 94/118 (79.6%). Skin eruption induced by an anti-tumor necrosis factor (TNF) were the most common diagnoses [46/118 (39%)], including psoriasiform dermatitis (PD) - 31/46 (67.4%) and inflammatory alopecia (IA) - 15/46 (32.6%). Of these, 18 patients (39.1%) continued the anti-TNF agent concomitantly with a topical or systemic anti-inflammatory agent to control the eruption. The remaining 28 patients (60.9%) discontinued the anti-TNF, of whom 16/28 (57.1%) switched to ustekinumab. These strategies effectively treated the majority [38/46 (82.6%)] of patients. Continuation of the anti-TNF was possible in a significantly higher proportion of patients with PD: 12/31 (38.7%) than only one in the IA group, p = 0.035. There was a higher switch to ustekinumab among the IA 7/15 (46.6%) compared with the PD 7/31 (22.6%) group, P = .09. Following IBD-DERMA advised intervention, IBD deteriorated in 9/4 6(19.5%) patients, 5/9 on ustekinumab (PD versus IA, P = NS).

CONCLUSION

Shared decision-making in an integrated IBD-DERMA clinic allowed successful control of skin eruptions while preserving control of the underlying IBD in more than 80% of cases. Patients with IA profited from a switch to ustekinumab.

Recurrent Neurological Episodes for 10 Years Preceding Skin Lesions in Neuro-Sweet Disease

An absence of skin lesions at the neurological onset may obscure the diagnosis of neuro-Sweet disease (NSD). We herein report a 32-year-old man with NSD in whom neurological symptoms preceded the development of skin lesions by 10 years. The patient exhibited four distinct neurological episodes: meningoencephalitis, scattered brain lesions, ocular flutter, and isolated seizures. Acute relapses responded to corticosteroid therapy, and the patient was successfully maintained on corticosteroid and dapsone combination therapy. NSD should be considered in the differential diagnosis of patients with recurrent neurological manifestations, especially with both meningeal and brain parenchymal involvement, even if no skin lesions are observed.

Exaggerated arthropod assault: Eosinophilic dermatosis in a patient with small lymphocytic lymphoma

Dermatologic reactions are commonly encountered in clinical practice. Providers must be aware of both the common and uncommon etiologies leading to these eruptions, particularly in patients with underlying malignancies. Establishing the appropriate etiology directs treatment of these conditions, which may be therapy directed at the malignancy itself.

Erythematous skin lesions with necrotic centers on lower extremities due to the use of ruxolitinib for primary myelofibrosis

Ruxolitinib is a small molecule JAK-2 inhibitor approved for the treatment of certain myeloproliferative neoplasms. Ruxolitinib-related skin toxicity is extremely rare. We report herein an unusual erythematous skin eruption with necrotic centers involving lower extremities in a patient with primary myelofibrosis treated with ruxolitinib. Awareness of this unusual skin toxicity with ruxolitinib becomes even more important as JAK-2 inhibition might soon find clinical applications in dermatology.

A Hyperpigmented Reticular Rash in a Patient on Peritoneal Dialysis

Chronically ill patients often develop uncommon exam findings. A 16-year-old female with end-stage renal disease secondary to immune complex-mediated glomerulonephritis on peritoneal dialysis (PD) developed a pruritic, hyperpigmented reticular rash on her abdomen, sparing the PD catheter insertion site. The rash appeared approximately 6 weeks after initiating PD. She used a heating pad nightly during PD for dialysis drain pain. Testing for systemic and autoimmune disease was negative. She was referred to dermatology, where the diagnosis of erythema ab igne (EAI), a well-described but less well-known hyperpigmented reticular cutaneous eruption caused by chronic exposure to low levels of infrared heat, was confirmed. The eruption is typically painless but is often pruritic. Common sources of heat include fires, stoves, portable heaters, heating pads, and laptop computers. The association between EAI and PD is unknown. Our patient discontinued the heating pad and her rash resolved.

Characterization of nivolumab-associated skin reactions in patients with metastatic non-small cell lung cancer

Immune checkpoint inhibitors have led to considerable therapy improvement in cancer patients. Autoimmune side effects including skin reactions are frequently observed. In melanoma, those include rash and vitiligo and were shown to be associated with a prolonged overall survival. Little is known about skin reactions in non-small cell lung cancer (NSCLC) patients during immunotherapy. Here, we retrospectively investigated immune-related adverse skin reactions (irAEs) in 40 patients with metastatic NSCLC treated with the anti-PD-1 antibody nivolumab. 7 out of 40 patients (17%) developed an irAEs. Skin irAEs correlated with tumor responses in 5 of 12 responders (42%) as compared to 2 of 27 non-responders (7%). Histologically, scaly plaques showed dermatitis consisting mainly of lymphocytes. We observed a positive correlation between skin irAEs and tumor responses in patients with NSCLC treated with nivolumab. Patterns of lymphocytic skin infiltration differed depending on the histological tumor subtype (adenocarcinoma versus squamous cell carcinoma NSCLC).

Skin manifestations of adult T-cell leukemia/lymphoma: clinical, cytological and immunological features

Adult T-cell leukemia/lymphoma (ATLL) is a malignancy of mature T cells caused by human T-cell leukemia virus type I. The endemic areas include Japan, especially in Kyushu, the Caribbean, Papua New Guinea, South America and Africa. Approximately 50% of ATLL patients exhibit skin manifestations. Cytologically, ATLL tumor cells are characterized by CD4(+) CD25(+) regulatory T-cell phenotype, high expressions of CCR4, and programmed cell death (PD)-1 and PD-ligand 1. The skin eruptions are categorized into six types: patch, plaque, multipapular, nodulotumoral, erythrodermic and purpuric. The overall survival of the eruption-bearing patients was poorer than that of the non-eruption-bearing patients in acute, chronic and smoldering types, but the survival levels of both groups were comparable in lymphoma type. The prognosis was poor in the order of: erythrodermic, nodulotumoral, multipapular/purpuric, plaque, then patch. Multivariate analysis revealed that the eruption type is an independent prognostic factor for ATLL. Patients may have other skin manifestations, secondary and infective lesions.