Fnu Shailesh

Vemurafenib-induced bilateral facial palsy

The United States Food and Drug Administration (FDA) approved Vemurafenib in August 2011, for treatment of melanoma with BRAF V600 mutation. It has shown improvement in the median overall survival of melanoma patients. The most common adverse effects of vermurafenib are arthralgia, rash, alopecia, photosensitivity and fatigue. Other infrequent and severe adverse reactions reported in patients include keratocanthomas, hypersensitivity, Stevens Johnson Syndrome, toxic epidermal necrolysis, uveitis, QT prolongation, and hepatotoxicity. We hereby present a case of bilateral facial palsy as an adverse effect of vemurafenib therapy, seen after six weeks of commencement of the drug. Complete resolution of the symptoms was seen when the patient was taken off vemurafenib.

Recurrent A V block following ablation for AVNRT.

Slow pathway modification has become the mainstay for the treatment of atrio-ventricular nodal re-entrant tachycardia (AVNRT) ablation because of high success rate and low incidence of complications. Our patient had a rare complication of slow pathway modification by radiofrequency ablation (RFA) in form of delayed complete heart block, occurring 10 days after the procedure and resolving in 6 weeks to normal conduction. Complete AV block is a rare immediate complication of RFA but can present weeks later. Transient atrio-ventricular (AV) block during the procedure is seen in all patients who develop delayed AV block and these patients should be monitored closely.

PREDICTIVE ACCURACY OF RESTING GRADIENT (PD/PA) FOR IDENTIFYING ISCHEMIC CORONARY LESIONS

Adenosine is used to induce maximal hyperemia during fractional flow reserve (FFR) measurement. Adenosine administration can be time consuming, with added cost and sometimes may have undesirable side effects. We evaluated the predictive accuracy of resting trans-lesional gradient (distal coronary

Phenazopyridine associated acute interstitial nephritis and review of literature

Abstract Phenazopyridine is a urinary analgesic; commonly seen side-effects of this drug include, orange discoloration of urine, methemoglobinemia, yellowish skin discoloration, hepatitis and acute renal failure. Various case reports with phenazopyridine associated acute renal failure secondary to acute tubular necrosis have been reported in the literature. Acute kidney injury in these patients is caused by either direct injury to renal tubular epithelial cells or secondary to pigment induced nephropathy from hemolytic anemia. Hypoxic injury from phenazopyridine-induced methemoglobinemia has been well documented. We report a case of biopsy proven acute interstitial nephritis, associated with therapeutic doses of phenazopyridine without any evidence of methemoglobinemia or other mechanism of renal injury. Clinicians should be aware of the toxicity of this commonly used drug and should look closely for signs of renal insufficiency. Identifying and stopping the offending medication stays as the first step, but recent studies indicate that early steroid administration improves renal recovery, as well as decreasing the risk of progression to chronic kidney disease with fibrosis and consequent permanent renal damage.

A patient with mexiletine-related psychosis

Mexiletine is a commonly used Class IB (Vaughan William classification) antiarrhythmic drug. We report a case of mexiletine-induced psychosis that was successfully managed by decreasing the dose and using alternative medications for management of ventricular tachycardia.

CLINICAL DECISION MAKING FOR THE HEMODYNAMIC GRAY ZONE (FFR 0.75-0.80) AND IMPACT ON LONG TERM OUTCOMES

A fractional flow reserve (FFR) value between 0.75 and 0.80 is considered the “gray zone” and outcomes data are limited in this group. We sought to evaluate the impact of revascularization vs. medical therapy alone (deferral) on long term outcomes for patients in the gray zone. Consecutive

Gartner Duct Cyst: CT and MRI Findings

A 29-year-old woman came to the outpatient clinic with complaints of chronic pelvic pain and dyspareunia. Her physical examination was normal. Her blood work and laboratory investigations were within normal range. Ultrasonography revealed a cystic mass posterior to vagina and uterus. Computed tomography (CT scan) showed an oblong structure with fluid density contents (Fig. 1). Patient had a magnetic resonance imaging (MRI) scan which revealed a large 10 9 9 9 4 cm cystic structure posterior to the uterus, originating along the posterior vaginal wall, representing Gartner duct cyst (Fig. 2a, b). The cyst was excised, and benignity of the lesion was confirmed by a histologic study. The diagnosis was consistent with Gartner duct cyst. Discussion

Buschke-Lowenstein tumor in a patient with decompensated cirrhosis.

Sir, A 57-year-old Caucasian male presented with continuous oozing of blood from a large exophytic growth over the abdomen and penile shaft. The patient reported a slowly enlarging exophytic growth over his penis [Figure 1a] and abdomen [Figure 1b] for past 35 years. He never sought medical attention for these; however, for the past 2 weeks, he was continuously oozing blood from these growths, requiring him to change clothes and bed sheets several times a day. Past medical history was significant for end-stage liver disease from untreated hepatitis C. At presentation, his hemoglobin was 6.6 and INR 1.9. During the course of hospitalization, patient was transfused as needed with reversal of coagulopathy; however the bleeding continued. Biopsy from both abdominal and penile growth showed increased mitosis and atypia, causing push effect, but lacked basement membrane invasion, [Figure ​[Figure2a2a and ​andb]b] consistent with diagnosis of Buschke-Lowenstein tumor (BLT). Our patient failed radiotherapy and surgery was not an option because of decompensated cirrhosis with irreversible coagulopathy. Figure 1 (a) Large, exophytic lesions over the penile shaft and scrotum; (b) Large, exophytic lesions on the abdomen Figure 2 (a and b) Histopathology of lesions illustrates papillomatosis, acanthosis, and keratin pearls with increased mitosis and atypia