Ismail Khalil

Autoerythrocyte sensitization (Gardner-Diamond) syndrome.

Abstract: We describe the clinical presentation and course of a patient with autoerythrocyte sensitization (Gardner–Diamond) syndrome, and review the literature for similar cases. A 37‐yr‐old female presented with recurrent episodes of painful ecchymotic bruising over the anterior aspect of both thighs. These episodes were precipitated by emotional stress. The diagnosis was confirmed by induction of similar lesions by intradermal injection of the patients own washed red blood cells and hemoglobin. The lesions did not recur for 6 months after the cause of her emotional stress was relieved. Autoerythrocyte sensitization (Gardner–Diamond) syndrome should be considered in the differential diagnosis of purpura, especially in patients with psychiatric problems.

Takayasu's arteritis presenting as fever of unknown origin:Report of two cases and literature review

OBJECTIVES This study reports two patients with Takayasus arteritis presenting with a fever of unknown origin (FUO) and reviews the literature on that association. METHODS We describe the clinical presentation, course, and outcome of the two patients, and reviewed the medical literature from 1968 till 1997 using MEDLINE and the key words fever, diagnosis, and Takayasus arteritis. RESULTS Takayasus arteritis is rarely reported as a cause of FUO. Noninvasive diagnostic techniques such as magnetic resonance imaging, computed tomography scanning, gallium-67 scintigraphy, and ultrasonography may help in the diagnosis of Takayasus arteritis in the prepulseless stage. CONCLUSION Takayasus arteritis should be considered in the differential diagnosis of FUO, especially in young women.

Lupus anticoagulant, Factor V Leiden, and methylenetetrahydrofolate reductase gene mutation in a lupus patient with cerebral venous thrombosis

We describe the case of a young Lebanese woman with systemic lupus erythematosus (SLE) and a positive lupus anticoagulant (LAC) who developed right internal jugular vein and sigmoid sinus thrombosis. Coagulation studies showed that in addition to the LAC the patient was heterozygous for the factor V (FV) Leiden mutation, and C677T mutation of the methylenetetrahydrofolate reductase gene. The high prevalence of FV Leiden in the eastern Mediterranean region suggests that we should probably screen our SLE patients in this area, especially those with anticardiolipin antibodies and/or LAC who have no history of thrombosis, for this and other thrombophilia markers. The detection of such abnormalities may have major practical consequences for the long-term management of these patients to prevent further thrombotic episodes.

High prevalence of prothrombin G20210A mutation among patients with deep venous thrombosis in Lebanon.

High prevalence of prothrombin G20210A mutation among patients with deep venous thrombosis in Lebanon -

Prevalence and treatment of cardiovascular risk factors in outpatients with atherothrombosis in the Middle East

Objective To characterise the risk-factor profile and treatment gaps among patients with, or at risk for, cardiovascular disease in the Middle East. Design Secondary analysis of a prospective observational study. Setting International multicentre study (Reduction of Atherothrombosis for Continued Health). Patients Stable outpatients with established cardiovascular disease or at least three risk factors for atherothrombosis. The present analysis was based on 840 patients from the Middle East. Intervention Observational study without a study-specific intervention. Main outcome measures A treatment gap was defined as at least one of the following: current cigarette smoking, total cholesterol ≥200 mg/dl, serum glucose ≥126 mg/dl or blood pressure of ≥140/90. Results The majority of Middle Eastern patients had hypertension (80.2%), more than half had a history of diabetes mellitus (52.3%), and a third had hypercholesterolaemia (34.1%). There was a high prevalence of obesity (38.6%), and nearly half the patients were former or current smokers (46%). β-Blockers and angiotensin-converting enzyme inhibitors were the most commonly prescribed antihypertensives (61.1% and 57.5%, respectively). Antiplatelet therapy (most commonly aspirin) and lipid-lowering drugs (most commonly a statin) were used in most patients (90.7% and 85.2%, respectively). Three-quarters of the participants (75.6%) had at least one uncontrolled risk factor. Conclusion Patients with atherothrombosis in the Middle East have a high prevalence of risk factors including alarming rates of diabetes mellitus and obesity. At least one risk factor is uncontrolled in the majority of patients, presenting a pressing need for improving the care of such patients in the Middle East.

High-output cardiac failure secondary to a large arteriovenous fistula: a persistent threat to the dialysis and kidney transplant patient.

High-output cardiac failure secondary to a surgically constructed arteriovenous fistula (AVF) is a rare entity that is usually under-diagnosed in the dialysis population. We herein present a case of a 35-year-old female who was diagnosed with high-output cardiac failure secondary to an AVF and later managed with surgical division of the fistula. Risk factors associated with this entity are discussed, and preventive screening strategies are recommended.

Tunneled dialysis catheter tip migration in obese and large-breasted individuals

A 65-year-old obese woman with chronic kidney disease presented with acute deterioration requiring hemodialysis. A right internal jugular tunneled hemodialysis catheter was placed, with a chest X-ray (CXR) confirming tip position at the right atrium. On day 10 post-insertion, she was referred from her dialysis center because of bleeding from the tunnel and catheter exit site. Inspection of the catheter failed to show any evidence of displacement and the fixation sutures were intact. CXR showed cephalad migration of the catheter tip (Figure 1). A new tunneled catheter was inserted into the right internal jugular vein, this time using a medial parasternal tunnel (Figure 2).

Venous Thromboembolism in Cancer Patients Referred to the American University of Beirut—Medical Center Secondary to Deep Vein Thrombosis; Occurrence and Risk Factors

Background/objectives: Cancer is a very important risk factor for the development of thromboembolic disorders. We conducted a retrospective study, in order to examine the rate of Deep vein thrombosis occurrence in cancer patients, as well as the effects of risk factors for DVT in cancer patients affected with DVT.Methods: 148 patients were enrolled in this study. Several risk factors for DVT were retrospectively examined with the main emphasis being age, gender, obesity, previous history of past thromboembolic phenomena and metastatic disease.Results: 55.5% of the study group was older than 60 years of age. Gender did not appear to be a significant risk factor. As for obesity, only 23% of our patients were defined as obese. An examination of previous history of thromboembolic conditions revealed that 16.8% had previous history of DVT, 1.3% developed a PE prior to presentation and 3.4% were positive for both DVT and PE. As for metastasis, 33.7% of our study population exhibited metastatic cancer upon their presentation. One interesting finding was that only 13 patients out of the 148 had been on DVT-prophylaxis prior to their admission.Conclusion: Cancer is an important risk factor for the development of thromboembolic phenomena, yet in most parts of the world, prophylaxis is discerned mostly through clinical judgement or local guidelines. With this in mind, and the additive effects of other risk factors, stricter medical practices and well-defined regimens should be set forth to protect cancer patients from these conditions.

Mondor’s Disease of the Breast in the Context of Inherited Thrombophilia

A 34-year-old previously healthy Lebanese woman presented to our attention for sudden, severe pain and redness in her right breast that started one month prior to presentation. A palpable cord was also noted in the right breast at the onset of symptoms, extending from the nipple towards the axilla. The pain and redness subsided gradually over three weeks, and the area later transformed into a fibrous cord which caused retraction of the nipple (Fig. 1). The patient denied any previous breast surgery, biopsy, inflammation, infection, or trauma. She had three noncomplicated full-term pregnancies and denied any spontaneous or induced abortions. The patient was a nonsmoker and denied any history of thromboembolic events. She was not on oral contraceptives or any other long-term medications. Her family history was significant for unprovoked upper extremity superficial thrombophlebitis (brother) and multiple strokes (mother). Mammography of the right breast did not reveal any abnormal findings, while magnetic resonance imaging (MRI) of the breasts (Fig. 2) showed asymmetry of the glandular tissues with a Y-shaped area of fibrosis compatible with a subacute stage of glandular tissue inflammation in the outer quadrant of the right breast. The patient had a normal complete blood count, prothrombin time, and activated partial thromboplastin time. Lupus anticoagulant testing through clotting assay was negative and anticardiolipin antibody testing through enzyme linked immunosorbent assay was nonrevealing. Fibrinogen, protein C, and antithrombin III levels were normal; however, protein S was low on two consecutive occasions two weeks apart (56.5% and 55.8%, respectively; reference range: 65–140%). A genetic thrombophilia work up was ordered. She had no evidence of the factor II (prothrombin) G20210A mutation but was found to be carrying the factor V Leiden (FVL) and methylenetetrahydrofolate reductase (MTHFR) C677T heterozygous mutations. The patient was thus diagnosed with Mondor’s disease of the breast and treated conservatively to relieve pain. Genetic thrombophilia counseling was offered for the patient and her family. Superficial thrombophlebitis of the mammary region, otherwise known as Mondor’s disease, is mainly observed after breast intervention, trauma, infection, or in the setting of malignancy. Our observation adds an additional risk factor, thrombophilia, and demonstrates that unprovoked thrombotic

Thromboangiitis obliterans and the inherited thrombophilias: does an association merit consideration?

Over a century ago, Virchow postulated the theory of a triad of abnormalities to explain the cause of thrombosis; specifically, vessel wall disorders, stasis, and increased coagulability. It has so far been shown that all three components play active roles in the pathogenesis of thrombotic phenomena. Moreover, it has become evident that thrombotic risk is a dynamic process resulting from an association between acquired risk factors and the inherited thrombophilias [1]. In light of this, we would herein like to share our experience with a patient who presented to our care for lower extremity thrombosis; for which a multitude of risk factors could be observed.