Mohammed Muqeet Adnan

Severe Hypocalcemia due to Denosumab in Metastatic Prostate Cancer.

Denosumab is a monoclonal antibody used for prevention of skeletal-related events (SREs) in patients with bone metastases from solid tumors. Hypocalcemia is a rare and dangerous side effect of the drug Denosumab. We present a case of a patient with metastatic prostate cancer who developed severe hypocalcemia after the administration of the drug. The patients vitamin D levels were low when checked after administration of the drug, which likely predisposed him to the development of hypocalcemia. He was placed on high doses of oral and intravenous (IV) calcium and vitamin D without any appreciable response in the serum calcium level. His ionized calcium remained below 0.71 mmol/L despite very high doses of oral and IV calcium supplements. During the hospital course, he developed hydronephrosis from the spread of a tumor and did not want to undergo percutaneous nephrostomy tube placement; therefore, it was decided to dialyse him for acute renal failure and to correct his hypocalcemia. Checking calcium and vitamin D levels prior to the administration of Denosumab is vital in preventing hypocalcemia. If hypocalcemia is severe and not responsive to high doses of vitamin D, oral and IV calcium, then hemodialysis with a high calcium bath can correct this electrolyte abnormality.

Black Cohosh and Liver Toxicity: Is There a Relationship?

Herbal supplements are commonly used by patients for various problems. It is a well-known fact that most patients do not tell their physicians about the use of herbal supplements unless they are specifically asked. As a result, sometimes important information regarding drug side effects is missed in history taking. During our literature search, we found several retrospective studies and other meta-analyses that claim a lacking or weak link between black cohosh use and hepatotoxicity. We present a case of a 44-year-old female who developed subacute liver injury demonstrated on a CT scan and liver biopsy within a month of using the drug to resolve her hot flashes and discuss a possible temporal and causal association between black cohosh use and liver disease. Since the patient was not taking any other drugs, we concluded that the acute liver injury was caused by the use of black cohosh. We agree with the United States Pharmacopeia recommendations that a cautionary warning about hepatotoxicity should be labeled on the drug package.

Distant skin metastases as primary presentation of gastric cancer.

Distant gastric metastasis to the skin is uncommonly a presenting symptom, although nonspecific paraneoplastic syndromes with dermatologic manifestation including diffuse seborrheic keratoses (Leser-Trelat sign), tripe palms, and acanthosis nigricans have been described in the literature. We report here the case of a 49-year-old woman with gastric adenocarcinoma who presented with cutaneous metastasis as an initial symptom. In our case, metastatic skin lesions responded significantly to EOX chemotherapy (epirubicin+oxaliplatin+capecitabine) despite progression of systemic disease. In similar presentations, a high index of clinical suspicion and skin biopsy are important.

Biventricular thrombi of nonischemic cardiomyopathy.

47 year old male with history of alcoholic liver cirrhosis came in with severe bilateral lower extremity pain and new onset acute bilateral limb ischemia. Vitals at admission were stable and physical examination showed clear cut cool bilateral lower extremities below both ankle joints with all the 10 toes being black suggesting gangrene. Bilateral dorsalis pedis and Posterior tibial pulses were not felt and could not be detected with dopplers. A transthoracic Echocardiogram revealed that the patient had an Ejection fraction of 10-15% with diffuse hypokinesis, also were noted multiple biventricular thrombi with the largest in the left ventricle measuring 50x30mm in size extending from anterolateral papillary muscle upto the septal myocardium. Evaluation with a cardiac and aortic catheterization revealed non obstructive coronaries, complete occlusion of the bilateral anterior tibial, posterior tibial and peroneal arteries at the ankle level with zero flow below bilateral ankle joints. No intervention could be performed and hence the patient was at first anti coagulated with heparin and then bridged to Coumadin. Patient was discharged to follow up with orthopedic surgery for bilateral amputations. Biventricular thrombi are generally seen in patients with a pro thrombotic state like anti phospholipid antibody syndrome, heparin induced thrombocytopenia induced thrombosis, hypereosinophilic syndrome. Cases have been reported in patients with viral myocarditis and libman sacks endocarditis. It is generally very rare to see multiple biventricular thrombi in patients with low Ejection Fraction.

Anti-GBM Disease in Pregnancy Acute Renal Failure Resolved After Plasma Exchange, Hemodialysis, and Steroids

Antiglomerular basement membrane (GBM) disease presenting during pregnancy is uncommon. We present a case of a pregnant female who presented with acute renal failure requiring dialysis due to anti-GBM disease. She responded well to plasma exchange, high-dose steroids, and hemodialysis. Cyclophosphamide was discussed but not given at the patient’s request due to concerns for the well-being of the fetus. Unfortunately, she suffered a spontaneous abortion in her eighth week of pregnancy. Subsequently, she had progressive improvement in her renal function and became hemodialysis independent at 2 weeks after diagnosis. Her renal function returned to baseline 3 months after diagnosis. We present this case in detail and review the literature regarding anti-GBM disease in pregnancy.

Anti-GBM of Pregnancy: Acute Renal Failure Resolved after Spontaneous Abortion, Plasma Exchange, Hemodialysis, and Steroids

Antiglomerular basement membrane disease presenting during pregnancy is very uncommon. We present a case of a pregnant female who presented with acute renal failure needing dialysis from Goodpastures disease. She responded very well to just plasma exchange, high dose steroids, and hemodialysis. Cyclophosphamide was never started on this patient. She had a spontaneous abortion in her 8th week of pregnancy and henceforth did very well to regain her renal function. Patient became hemodialysis independent at 2 months and returned to her baseline kidney function at 6 months. We present this remarkable case of recovery from acute renal failure in a patient with anti-GBM disease. We think the flare-up of renal failure was pregnancy related which resolved after spontaneous abortion.