Karan Seegobin

Necrotizing Pseudomonas aeruginosa Community-Acquired Pneumonia: A Case Report and Review of the Literature

Lung cavities are not typically associated with community-acquired pneumonia (CAP). CAP due to P. aeruginosa is rare and even less commonly causes necrotizing pneumonia. We report a case of P. aeruginosa CAP that progressed to necrotizing pneumonia and was eventually fatal. Procalcitonin (PCT) has been well investigated in guiding antibiotic therapy (especially CAP) in adults. In this case, PCT at presentation and sequentially was negative. We discuss this caveat and present hypotheses as to the sensitivity and specificity of PCT and C-reactive protein (CRP) in these patients. To better characterize P. aeruginosa CAP, we undertook a review of cases indexed in PubMed from 2001 to 2016 (n = 9). The data reveal that risk factors for P. aeruginosa CAP include smoking, alcohol use, obstructive lung disease, sinusitis, and hot tub use. The route of infection for P. aeruginosa CAP remains unknown. One of the most interesting findings on reviewing cases was that P. aeruginosa CAP involves the right upper lobe in the vast majority. We suggest that when physicians in the community see patients with distinctly upper lobe necrotizing or cavitary pneumonia, they should consider P. aeruginosa in their differential diagnosis. Further studies are needed to clarify route of infection, role of PCT and CRP, and optimal therapy including drug and duration.

Severe beta blocker and calcium channel blocker overdose: Role of high dose insulin

&NA; A 54‐year‐old female presented after taking an overdose of an unknown amount of hydrochlorothiazide, doxazocin, atenolol and amlodipine. She was initially refractory to treatment with conventional therapy (intravenous fluids, activated charcoal, glucagon 5 mg followed with glucagon drip, calcium gluconate 10%, and atropine). Furthermore, insulin at 4 U/kg was not effective in improving her hemodynamics. Shortly after high dose insulin was achieved with 10 U/kg, there was dramatic improvement in hemodynamics resulting in three of five vasopressors being weaned off in 8 h. She was subsequently off all vasopressors after six additional hours. The role of high dose insulin has been documented in prior cases, however it is generally recommended after other conventional therapies have failed. However, there are other reports that suggest it as initial therapy. Our patient failed conventional therapies and responded well only with maximum dose of insulin. Physicians should consider high dose insulin early in severe beta blocker or calcium channel blocker overdose for improvement in hemodynamics. This leads to early discontinuation of vasopressors. It is important that emergency physicians be aware of the beneficial effects of high dose insulin when initiated early as opposed to waiting for conventional therapy to fail; as these patients often present first to the emergency department. Early initiation in the emergency department can be beneficial in these patients.

A case of worsening pulmonary arterial hypertension and pleural effusions by bosutinib after prior treatment with dasatinib

A 52-year-old man with a past medical history of chronic myeloid leukemia (CML) in remission developed progressive shortness of breath over a two-month period. He was initially treated with dasatinib for four years, until developing pulmonary arterial hypertension (PAH) with pleural effusions. His symptoms improved after stopping dasatinib. He was then switched to bosutinib for approximately one year, which was then stopped before admission due to worsening shortness of breath. His initial workup showed bilateral pleural effusions with severe PAH and cor pulmonale. He had symptomatic improvement with PAH-specific therapy following discontinuation of the bosutinib. The life expectancy of CML patients has increased in the era of the tyrosine kinase inhibitors (TKIs), and managing adverse events (AEs) of the TKIs and improving quality of life are becoming more important. Pulmonary hypertension (PH) and pleural effusions are rarely reported AEs of bosutinib. More reports with PH and pleural effusions arising after bosutinib use in patients previously treated with dasatinib is furthermore concerning. In this era with novel chemotherapeutic agents, physicians ought to be weary of the significant morbidity implicated by these agents in the lives of patients.

Increased risk of arterial thromboembolic events with combination lenalidomide/dexamethasone therapy for multiple myeloma

ABSTRACT Introduction: Cancer associated thrombosis is a leading cause of morbidity and mortality. Research and guidelines have focused on venous thromboembolic events (VTE). Within the past decade, combination lenalidomide and dexamethasone has become a standard of therapy for multiple myeloma and is now widely used. In these patients, the risk of arterial thromboembolic events (ATE) has not been addressed to the same extent as VTE. Areas discussed: Presented is a targeted review of published data on ATE in MM patients on combination lenalidomide/dexamethasone therapy. Incidence, clinical presentations, prognosis, mechanisms and thromboprophylaxis are discussed. A framework for approaching ATE/VTE in these patients is suggested. Expert commentary: There is an increased incidence of ATE in this population, primarily cerebrovascular and cardiovascular events. ATE is associated with poorer prognosis and its prevention must be an important goal of management. It is suggested that on initiating treatment, a combined VTE/ATE risk assessment should be performed and thromboprophylaxis initiated for a minimum of 6 months. As newer immunomodulatory therapies are developed, thromboembolic risk must be assessed early on. Further studies are needed to determine the optimal strategy to reducing both VTE and ATE in this population.

Fatal Type B Lactic Acidosis Associated With Metastatic Colorectal Cancer: A Case Report With Review of Literature, Pathogenesis, and Treatment

Type B lactic acidosis associated with malignancy is a life-threatening complication and mostly seen in hematological malignancies but can also be seen in solid tumors. We report a rare case of a 64-year-old female diagnosed with metastatic adenocarcinoma of the colon with liver metastasis associated with severe type B lactic acidosis. We discuss pathophysiology, previously reported cases, and their outcomes. The most widely used therapies are bicarbonate infusion, thiamine supplementation, chemotherapy, and supportive care but is associated with poor outcomes, and no standard treatment recommendations are available. Early chemotherapy administration remains the only intervention that has shown some survival benefit. Physicians should be aware and proactive for early diagnosis and management of this condition with further research needed to guide optimal therapy.

Coexistent Ipsilateral Internal Carotid Artery Occlusion and Cerebral Venous Thrombosis in Hepatitis C

A 58-year-old male, known to have hepatitis C virus (HCV), presented with intermittent headaches and left-sided sensorimotor symptoms. There were no focal neurological deficits on examination. Electrocardiogram was unremarkable. Computed tomography angiography head and neck displayed extracranial right internal carotid artery occlusion. Magnetic resonance imaging showed right cortical vein thrombosis, with hemorrhagic infarction. Echocardiography with bubble study was unremarkable. Hypercoagulable workup was significant for protein S deficiency. He was treated with warfarin for 6 months. Repeat protein S levels remained low 9 months later. The coexistence of arterial and venous thrombotic events gives rise to a limited differential. In this case, it may be related to chronic HCV infection. The underlying pathogenesis is not clear; however, it is possible the patient had chronic high-grade internal carotid artery stenosis, which occluded leading to his presenting symptoms. The cortical vein thrombosis is likely an incidental finding here. The extent by which HCV contributed to the cerebral thrombosis and carotid artery occlusion in our case is not clear; however, the hypercoagulable and atherosclerotic properties of the virus cannot be disregarded. The virus can promote carotid atherosclerosis and cerebral venous thrombosis as well as other venous and arterial thromboembolic events. Furthermore, HCV is associated with impaired venous flow and procoagulant properties, which can fuel a hypercoagulable state. Also of note cirrhosis is associated with protein S deficiency. We recommend considering an underlying hypercoagulable state including both arterial and venous thrombosis in HCV infection.

Pilot study on the occurrence of multiple cancers following cancer-related therapy at the University of Florida, Jacksonville (2011–2016)

New primary cancers can occur in patients with a previous cancer. Among the risk factors, therapies such as chemotherapy, radiotherapy, and hormonal therapy have been associated with the development of neoplasms. Second cancers most commonly develop 5–10 years after the initial tumor. We observe the implications of cancer-related therapy in the development of a new tumor. We looked at 602 patients who had their first cancer diagnosed in 2011 and calculated the number of different primary cancers between 2011 and 2016 for each patient. Twenty-four patients had a second cancer within 5 years from the first diagnosis and there were no patients with a third cancer. There was no statically significant difference in the rates of second cancers after exposure to chemotherapy, radiotherapy, hormonal therapy, or any combination of these (p=0.738). Of the second cancers reported after 2011, renal, uterine, cervical, and lung cancers were the most frequently reported. Additionally, there was no statically significant difference among the rates of second cancers in men versus women (p=0.467), as well as among whites versus blacks (p=0.318). We conclude that while new primaries can occur after one cancer, there was no increased risk after exposure to different cancer-related therapies. With increased focus on the primary disease, there is a higher likelihood of missing another primary lesion. This is important as the practical implications of managing multiple primaries are rarely discussed.

Dynamic right ventricular outflow tract obstruction from a pedunculated cardiac metastasis

A 48-year-old African–American female presented to the Emergency Department with a complaint of chest discomfort and dyspnea. The patient was known to have squamous cell carcinoma of the bladder diagnosed 3 months prior, with invasion into the muscularis propria, staged as T2NxMx. On auscultation, there was a soft systolic murmur. Electrocardiography showed that sinus tachycardia and cardiac biomarkers were within normal limits. CT angiography (CTA) done in the Emergency Room excluded pulmonary emboli. Transthoracic echocardiography revealed normal cardiac function with preserved ejection fraction. However, the right ventricle was enlarged with an echodense round mass in the distal RVOT (arrow, Fig. 1a, b). The mass measured 2.2 × 1.9 cm (Fig. 1c) and was pedunculated with independent motion (see supplemental video) leading to turbulent flow in the RVOT. The rest of the examination was positive only for a small circumferential pericardial effusion. 18FDG PET scanning strongly suggested that this was a metastatic lesion. There was intense 18FDG uptake centered in the RVOT (Fig. 1d) with extension proximally and distally and SUV of 12.8. Unfortunately the patient died 3 months later with confirmed widespread metastatic disease from aggressive carcinoma of the bladder. Metastatic cardiac masses are typically from mediastinal or thoracic primary neoplasms or melanoma [1]. Metastases disseminate to the heart via three main routes: lymphatic, hematogenous, and direct or transvenous. The most frequent carcinomas implicated are breast and lung, with infradiaphragmatic tumors far less common [2]. Malignant melanoma, lymphoma, leukemia, and sarcoma usually spread hematogenously. Extracardiac tumors may also reach the atria and even the chambers of the heart by transvenous extension. To note, intraluminal growth of renal cell carcinoma through the renal vein into the vena cava and right atrium occurs in 1% of these tumors [2, 3]. There are only a handful of cases reported with cardiac metastasis from urothelial carcinoma [4]. Furthermore, metastases also usually arise from the intraventricular or septal myocardium or involve the valvular apparatus. This case is unique in that the tumor was pedunculated and mobile in the RVOT. The “tethered ball” morphology resulted in symptomatic obliteration of the RVOT. RVOT pedunculated metastasis is extremely rare, but, as this case demonstrates can lead to dynamic obstruction. It should be considered in the differential diagnosis of dyspnea or chest discomfort in the patient with cancer, and echocardiography should be done with particular attention to the RVOT on parasternal long axis and subcostal short axis views as demonstrated.

Sarcoidosis presenting with facial swelling (Heerfordt syndrome)

Sarcoidosis is one of the “great masqueraders” of medicine and can present with atypical facial swelling. Imaging and biopsy confirm the diagnosis.

Coexistent Breast Cancer and Essential Thrombocythemia: How We Addressed the Therapeutic Challenges

Essential thrombocythemia (ET) occurring with breast cancer is uncommon; the therapeutic approach varies and poses a challenge. A 65-year-old female presented to us after being diagnosed with hormone positive, HER2-negative infiltrating ductal carcinoma. She had a platelet count of 600 thou/cu mm. Her JAK2 mutation was positive. Bone marrow biopsy showed increased megakaryocytes. She was diagnosed with ET in the setting of breast cancer. She underwent breast conservation surgery after which aspirin was resumed. Anticipating thrombocytopenia during chemotherapy and given the absence of data combining hydroxyurea with standard chemotherapy used for breast cancer, we felt it prudent to delay cytoreductive therapy for her ET until after completion of breast cancer treatment. Her average platelet count during chemotherapy was 480 thou/cu mm with the lowest being 377 thou/cu mm. Her platelet count remained at goal between 300 and 350 thou/cu mm after four months of hydroxyurea.