Arie Markel

Allopurinol-Induced Recurrent DRESS Syndrome : Pathophysiology and Treatment

Hyperuricemia is present in approximately 5% of the population. The vast majority is asymptomatic and at no clinical risk. Allopurinol, an analog of hypoxanthine, has been widely used in clinical practice for more than 30 years for the treatment of hyperuricemia and gout. Two percent of patients develop a mild exanthema when on this drug, which usually resolves after withdrawal of the drug. A syndrome characterized by exfoliative dermatitis, hepatitis, interstitial nephritis, and eosinophilia, termed allopurinol hypersensitivity syndrome, has been described, and its etiology related to the accumulation of one of allopurinols metabolites, oxypurinol, of which clearance is decreased in the setting of renal insufficiency and the use of thiazide diuretics. The term DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) Syndrome has been recently used to describe an entity presenting with similar features.

Copy and Paste of Electronic Health Records: A Modern Medical Illness

Many of the problems describedregarding the “copy and paste” issue are of the same mag-nitude at our Medical Center.As the director of one of the departments of internalmedicine at our hospital, I have the opportunity to fre-quently review patients’ charts and encounter the problemswith copy and paste. Medical diagnosis in previous admis-sions that have no relevance for the present hospitalizationare repeated and copied from one summary to the other.Previous medications are copied and printed as if they werethe patient’s current treatment even if the patient is nolonger taking them. Data presented in a previous hospital-ization are repeated without changing the details or actual-izing the date; subsequently the reader may not be able tounderstand or may misinterpret the data. Much informationfrom past reports, for example, in admitted patients withcoronary heart disease, is copied from previous charts andpresented in the history of the present illness as a never-ending paragraph that is repeated to exhaustion with eachhospitalization, whereas the actual and relevant history ofthe present illness is briefly presented in one small singleline.On some occasions, the same information is repeatedover and over. In one of the charts I reviewed, the patientwas referred, at his discharge, to a gastroenterologic con-sultation to one of our colleges at our Medical Center.Because this information was not in accordance with thedata presented in the chart, I looked for and realized that thesame sentence appeared in a previous discharge. By review-ing older hospitalizations, I saw that the same reference tothe gastroenterologist with the same details was repeatedagain and again in previous hospitalizations and in severaldepartments of our hospital by different physicians

Doppler Ultrasound in the Diagnosis of Venous Thrombosis

Deep vein thrombosis (DVT) has known morbidity and mortality. New noninvasive techniques such as B-mode scanning and Doppler ultrasonography (duplex) are highly accurate in the diagnosis of this problem but are relatively expensive and time consuming. Continuous-wave Doppler, a precursor noninvasive technique, is simple, cheap, and easy to perform at the patients bedside. To test the effectiveness of this technique the authors prospectively studied patients with clinical suspicion of DVT by Doppler ultrasound and compared the results with those from venography. During fourteen consecutive months, patients with a clinical suspicion of DVT underwent continuous-wave Doppler examination of both inferior limbs. Each case was diagnosed as positive, negative, or inconclusive. In addition, the patients underwent a questionnaire regarding risk factors, symptoms, and mean relevant physical findings. Doppler examination was blinded to venography results. A total of 116 patients with clinical suspicion of DVT were examined by Doppler ultrasound. Their mean age was fifty-five years (range: eighteen to eighty-eight). There were 57 men and 59 women, and from this group a total of 40 patients underwent both Doppler ultrasound examination and venography in the course of forty-eight consecutive hours. When cases with an inconclusive result were excluded, Doppler ultrasound showed a sensitivity of 89%, a specificity of 100%, and an accuracy of 94% for the diagnosis of DVT when compared with venography. When a similar analysis was done for the proximal named veins, continuous-wave Doppler examination showed a very high specificity and positive predictive value and a moderate sensitivity and negative predictive value. (continued on next page) In the entire group of patients with a Doppler ultrasound examination (n=116), 48 cases had a positive study. Prolonged bed rest, previous surgery, and previous DVT were the most frequent risk factors, pain and swelling the most frequent symptoms, and edema and tenderness the main clinical signs. In patients without DVT (n=57), trauma, malignant obstructing tumors, and cellulitis were the most frequent final diagnoses. The study was inconclusive in 11 patients. In conclusion, continuous-wave Doppler is accurate and may be used as the initial technique in the diagnosis of DVT. Cases that are inconclusive, or cases in which clinical findings are in evident contradiction to Doppler findings, should undergo duplex examination or venography.

Allopurinol Hypersensitivity and DRESS Syndrome

In a recent article by Tauche et al, a patient who develped a hypersensitivity reaction that included skin rash, ever, liver and renal test abnormalities, and eosinophilia, as described, and the reported set of findings was named y the authors as “allopurinol hypersensitivity syndrome.” lthough this term has been used in the past to describe hese features, the name Drug Rash with Eosinophilia and ystemic Symptoms (DRESS) syndrome has been more ecently introduced to describe the association of a drugnduced exanthema together with multi-organ abnormalities nd eosinophilia. This syndrome has been more frequently elated to the administration of aromatic anticonvulsants phenytoin, phenobarbital, carbamazepine) and sulphoamides, but other drugs have been reported as well. An ssociation with some viral diseases also has been escribed. DRESS syndrome is characterized by skin rash, fever, ymph node enlargement, and singleor multiple-organ inolvement, which starts within 8 weeks after the initiation f therapy. The skin disease is characterized by an infiltrated aculopapular eruption and facial edema, often more arked in the periorbital region. Hematologic abnormalities, specially eosinophilia and mononucleosis-like atypical lymhocytosis, also are common. The syndrome develops 2-6 eeks after commencing medication. The pathophysiology of his syndrome seems to be immunological. A connection with uman leukocyte antigen subtypes has been reported. Allopurinol-induced DRESS syndrome shares features imilar to other cases of drug-induced DRESS. It is more

Toxic effects of hydrogen sulfide: experience with three simultaneous patients.

Learning Point for Clinicians-H2S-QJM Hydrogen sulfide (H2S) is a colorless gas found in the industry and in places such as sewers. It can cause severe intoxication resulting in respiratory and neurological damage, and even death. Three men with intoxication by this compound are described. Methods for prevention of this problem should be urgently implemented. Three healthy workers attending cleaning operation were found in a critical condition inside a 5-m sewage manhole. The first victim, a 50-year-old man entered the pit and after a few minutes collapsed and lost consciousness. Another worker, a 22-year-old man entered the manhole to rescue him, but suddenly developed shortness of breath, stupor and rapidly entered an unconscious state. A third worker attempting to reach the other two co-workers felt dizzy and collapsed into …

Could a Coagulation Nurse Liaison Improve Compliance With Venous Thromboembolism Prophylaxis in Medical Patients

Medical patients worldwide are undertreated with venous thromboembolism prophylaxis. Our hypothesis was that the rate of prophylactic anticoagulation therapy for high-risk patients would improve with the use of a coagulation nurse liaison. Six months after appointing a nurse for this role, prophylaxis rates significantly improved, and patients were more likely to receive appropriate thromboprophylaxis. A coagulation nurse liaison substantially improves thromboprophylaxis in a medical ward.

The Dilemma on Refusing Patients' Care

I read with interest the recent editorial by Joseph S. Alpert on refusing to participate in the care of certain patients. I believe that each one of us is confronted daily with patients who are not exactly our “cup of tea.” Usually, we “swallow” our pride and try to behave as objectively as possible when treating them. The problem is more difficult when the patient is somebody whose position or actions go against our own interests and values or even our entire way of life and existence. Recently, we had several patients on a hunger strike admitted to our Internal Medicine Ward for observation and treatment. These patients were Arabs in prison for terrorist activities. Although I was not informed of the precise activity these individuals had been involved in, I could not rule out their participation in violent actions that had included murder, and therefore, I felt a strong sense of antipathy when treating them. Despite these feelings, I took care of them and tried to act as objectively as was possible. One of these patients spent a long time in our ward (on a prolonged hunger strike), and I had the opportunity to see him frequently and treat him during his hospitalization. He was a quiet and cooperative patient who behaved politely,

D-dimers and computed tomography for pulmonary embolism: when and how.

I read with interest the paper by Adams et al and the corresponding editorial by Stern. I found their conclusions xceptionally relevant and identified with their remarks. For the last years, we noticed the growing number of omputed tomography angiography studies (CTA) perormed in the Emergency Department of our Medical Cener for symptoms of dyspnea from different and nonspecific auses, and the high number of negative CTAs. We comented to our peers that those CTAs seemed unnecessary nd exposed the patients to unwanted radiation and other ide effects. As already commented years ago by Kline et al, emergency medicine specialists often feel compelled to order a D-dimer test in patients with dyspnea or pleuritic chest pain, even when the clinician recognizes a very low pretest probability. This exaggerated practice of ruling out pulmonary embolism and overdoing D-dimer tests frequently brings about a false-positive result that demands expensive, hazardous, and time-consuming radiological imaging. On the other hand, another relevant question is over the right attitude that should be adopted through high, or higher than normal, D-dimer values. Past recommendations and algorithms involving D-dimer values in patients with suspected venous thromboembolism stressed the importance of low or negative values of D-dimer in order to rule out venous thromboembolism, but did not indicate what to do ith a higher than normal value. The paper by Adams et al showed the prevalence of ulmonary embolism in patients with unlikely pulmonary mbolism and a positive D-dimer to be 142/1425 (10.0%).