Bhradeev Sivasambu

Cocaine-Induced Delayed Recurrent Vasculitis: A 4-Year Follow-Up

Patient: Female, 51 Final Diagnosis: Cocaine induced vasculitis Symptoms: — Medication: — Clinical Procedure: None Specialty: Rheumatology Objective: Rare disease Background: Cocaine is a highly abused substance in United States with almost 70 % of cocaine adulterated with levamisole. It is known to cause vasculitis involving multiple organs due to its direct toxic effect and by the contribution of levamisole or a combined effect of both. Case Report: A 51-year-old woman complained of painful erythematous rash in her hands and lower extremities that started few hours after smoking cocaine and progressed to blistering dark lesions in her lower extremities. She denied any other systemic complaints. Although she has been smoking cocaine for more than 35 years, these skin eruptions started only 4 years ago. Examination revealed tender retiform purpura in the hand and tender retiform purpura with hemorrhagic bulla in the legs. Initially, she had only a significantly positive atypical p-ANCA and later developed combined positivity of both Myeloperoxidase (MPO) and Anti-proteinase-3(PR3) antibodies with a p-ANCA pattern on immunofluorescence. We report a unique case of cocaine (likely contaminated with levamisole)-induced delayed recurrent vasculitis with varying vasculitic antibodies over the years. Conclusions: This case highlights the fact that patients can develop cocaine-related vasculitis after many years of uneventful abuse. Cocaine, with its adulterant levamisole, has the propensity to trigger diverse immunological reactions, which is evident by the varying antibody profile seen in the same patient over time.

Spontaneous iliopsoas haematoma: a complication of hypertensive urgency

Iliopsoas haematoma is a rare clinical entity which can be life threatening in extreme cases. We are reporting a case of iliopsoas haematoma as a complication of hypertensive urgency. A 67-year old woman presented to emergency room with hypertensive urgency and hip pain. During hospitalisation, her haemoglobin was decreasing and on further evaluation, she did not have any signs of external bleeding and laboratory results were not suggestive of haemolysis. CT scan of abdomen and pelvis revealed a spontaneous iliopsoas haematoma. A likely explanation for this presentation in the absence of coagulopathy and trauma is very high blood pressure. Patient was on low-dose aspirin at home which could have further aggravated her bleeding due to platelet dysfunction. She was managed conservatively with blood transfusions and blood pressure was reduced to target after which she recovered.

Acute Portomesenteric Venous Thrombosis following Laparoscopic Small Bowel Resection and Ventral Hernia Repair.

Acute portomesenteric venous thrombosis is a rare but life-threatening complication of laparoscopic surgery that has been described in literature. Prompt diagnosis and early initiation of treatment are vital to prevent life-threatening complications such as mesenteric ischemia and infarction. A 51-year-old lady had laparoscopic small bowel resection and primary anastomosis with ventral hernia repair 4 weeks earlier for partial small bowel obstruction. Her postoperative period was uneventful and she was discharged home. Four weeks after surgery she developed watery diarrhea and generalized abdominal pain for four-day duration. A computed tomography of the abdomen revealed portomesenteric venous thrombosis although a computed tomography of abdomen before surgery 4 weeks back did not show any portomesenteric venous thrombosis. We are reporting a case of acute portomesenteric venous thrombosis as a complication of laparoscopic surgery.

Gallbladder adenocarcinoma and paraneoplastic parathyroid hormone mediated hypercalcemia

Parathyroid hormone mediated hypercalcemia is not always exclusively primary hyperparathyroidism and rarely could be due to ectopic parathyroid hormone secretion from tumor cells. We present a case of 86-year-old female with metastatic gall bladder adenocarcinoma diagnosed eight months back who presented with generalized fatigue and poor oral intake and was found to be hypercalcemic with elevated parathyroid hormone levels. Imaging with technetium 99 m sestamibi scintigraphy with dual phase, subtraction thyroid scan (dual isotope scintigraphy), magnetic resonance imaging and ultrasonography did not demonstrate any parathyroid lesion in normal or ectopic sites. We believe that the tumor cells were the source of ectopic parathyroid hormone secretion as we had excluded all the other possibilities with extensive combined imaging thereby increasing the sensitivity of our testing. We report the first case of metastatic gall bladder adenocarcinoma with paraneoplastic ectopic parathyroid hormone secretion.

HbSC Disease and Spontaneous Epidural Hematoma with Kernohan's Notch Phenomena.

Spontaneous (nontraumatic) acute epidural hematoma is a rare and poorly understood complication of sickle cell disease. A 19-year-old African American male with hemoglobin SC disease (HbSC) presented with generalized body aches and was managed for acute painful crisis. During his hospital stay he developed rapid deterioration of his mental status and computed topography revealed a spontaneous massive epidural hematoma with mass effect and midline shift with Kernohans notch phenomena for which urgent craniotomy and evacuation was done. We report the first case of HbSC disease associated with catastrophic epidural hematoma progressing to transtentorial herniation and Kernohans notch phenomena within few hours with rapid clinical deterioration. The etiopathogenesis and the rare presentation are discussed in detail in this case report.

Legionnaires disease presenting as acute kidney injury in the absence of pneumonia

Legionnaires disease is a pneumonic illness with multisystem involvement. In 1987, Haines et al reported the only reported case of isolated renal disease of legionellosis without concurrent respiratory disease. A 62-year-old man presented with generalised weakness and malaise and watery diarrhoea, and was found to have acute kidney injury on admission. He was initially managed as acute gastroenteritis complicated with dehydration and acute kidney injury with intravenous hydration. Despite adequate hydration, his renal function was worsening day by day. Later in the course of his sickness he developed pneumonic illness and was diagnosed with Legionnaires disease after a positive urine antigen test. We are reporting the second case of Legionnaires disease presenting as an isolated acute kidney injury in the absence of respiratory symptoms on presentation.

Kikuchi-Fujimoto Disease Associated with Symptomatic CD4 Lymphocytopenia

Kikuchi-Fujimoto disease is a rare benign condition of necrotising histiocytic lymphadenitis with unknown aetiology. We describe here a 30-year-old African American female who presented with fever, generalized rash, cervical lymphadenopathy, and oral candidiasis and was found to have Kikuchi-Fujimoto disease on lymph node biopsy with low CD4 count. The initial presentation was concerning for acute retroviral infection. Her HIV serology and HIV RNA PCR were negative however she had low CD4 count with reversal of CD4/CD8 ratio. Although low CD4 count has been associated with autoimmune disease, it has not been described with Kikuchi-Fujimoto disease. We report the first case of Kikuchi-Fujimoto disease associated with symptomatic CD4 lymphocytopenia.