Shahzaib Nabi

Warfarin Dosing and Time Required to Reach Therapeutic International Normalized Ratio in Patients with Hypercoagulable Conditions

Objective: The purpose of this study was to analyze the difference in duration of anticoagulation and dose of warfarin required to reach a therapeutic international normalized ratio [(INR) of 2 to 3] in patients with hypercoagulable conditions as compared to controls. To our knowledge, this study is the first in the literature to delineate such a difference. Materials and Methods: A retrospective chart review was performed in a tertiary care hospital. The total study population was 622. Cases (n=125) were patients with a diagnosis of a hypercoagulable syndrome who developed venous thromboembolism. Controls (n=497) were patients with a diagnosis of venous thromboembolism in the absence of a hypercoagulable syndrome and were matched for age, sex, and race. Results: The total dose of warfarin required to reach therapeutic INR in cases was higher (50.7±17.6 mg) as compared to controls (41.2±17.7 mg). The total number of days required to reach therapeutic INR in cases was 8.9±3.5 days as compared to controls (6.8±2.9 days). Both of these differences were statistically significant (p<0.001). Conclusion: Patients with hypercoagulable conditions require approximately 10 mg of additional total warfarin dose and also require, on average, 2 extra days to reach therapeutic INR as compared to controls.

A Rare Case of Erdheim-Chester Disease and Langerhans Cell Histiocytosis Overlap Syndrome

A 48-year-old woman with a past medical history of seizures and end-stage renal disease secondary to obstructive uropathy from retroperitoneal fibrosis presented to the emergency department with seizures and altered mental status. A Glasgow Coma Scale of 4 prompted intubation, and she was subsequently admitted to the intensive care unit. Magnetic resonance imaging of the brain performed to elucidate the aetiology of her seizure showed a dural-based mass within the left temporoparietal lobe as well as mass lesions within the orbits. Further imaging showed extensive retroperitoneal fibrosis extending to the mediastinum with involvement of aorta and posterior pleural space. Imaging of the long bones showed bilateral sclerosis and cortical thickening of the diaphyses. Imaging of the maxillofacial structures showed osseous destructive lesions involving the mandible. These clinical and radiological features were consistent with a diagnosis of Erdheim-Chester disease; however, the patients skin biopsy was consistent with Langerhans cell histiocytosis.

VZV encephalitis following successful treatment of CMV infection in a patient with kidney transplant.

A 73-year-old woman with a history of deceased donor kidney transplantation and a recent cytomegalovirus (CMV) infection, presented to the emergency department with an altered mental status. She was found to have varicella zoster virus VZV encephalitis based on cerebrospinal fluid analysis and was treated successfully with intravenous valaciclovir with an improvement in her mental status. A review of the literature shows very few case reports on patients with kidney transplantation developing VZV encephalitis. A few case reports and studies report an association between CMV and VZV infection. In these patients, CMV infection can cause a marked decline in immunity and this predisposes them to other infections. Such associations have also been reported between other types of virus infections from the Herpesviridae family. The risk of disseminated VZV infection increases in the presence of CMV infection.

Unprovoked Saddle Pulmonary Embolism in a Patient with Shy-Drager syndrome: Are They Related?

There have been previous studies that suggested that patients with Parkinson’s disease are at an increased risk of thrombosis, but could Shy-Drager syndrome, which entails Parkinsonian features, be a risk factor for thrombosis also? Our patient is a 54-year-old male with Shy-Drager syndrome who presented to the emergency department with acute onset of pleuritic chest pain and shortness of breath. Initial work-up showed normal electrocardiogram, negative troponins, normal complete blood count, and normal chemistry panel, but an elevated D-dimer. Computed tomography of the chest with intravenous contrast was performed which revealed a large saddle pulmonary embolus extending into the right and left pulmonary arteries. Interestingly, the patient remained hemodynamically stable throughout his stay in the hospital.

Is He Another Drug Addict Asking for Narcotic Pain Medications

There have been many reported cases of complications such as hypertensive emergencies, strokes, myocardial infarctions and deaths arising from cocaine use. In this case report, we present a rare complication arising from chronic cocaine use. A 58 year old male with past medical history of hypertension, chronic obstructive pulmonary disease (COPD) and cocaine abuse, presented to the emergency department because of acute onset difficulty in breathing. Review of systems was positive for chronic right knee pain. His blood pressure was found to be elevated and his urine toxicology screen was positive for cocaine and amphetamines. Cocaine induced bronchospasm with COPD exacerbation was diagnosed and the patient was admitted to the pulmonology floor and was started on nebulization treatments, steroids and doxycycline. A right knee X-ray was obtained to evaluate patient’s chronic knee pain which showed multiple areas of necrosis in femur and fibula, suggestive of cocaine induced osteonecrosis.

Analyzing multiple risk factors in patients with sarcomas. A case-control study.

CONTEXT Sarcomas are a rare group of malignancies. Very little is known about their risk factors. AIMS The aim was to evaluate different risk factors in patients with sarcomas and to determine the median age at diagnosis, differences in race, gender, histological grades and staging in sarcoma patients. SETTINGS AND DESIGN A retrospective case-control study was conducted in a tertiary care hospital in the USA. This included patients diagnosed with sarcomas from year 2000 to 2010. MATERIALS AND METHODS Data were extracted with the help of electronic medical records using International Classification of Diseases, Ninth revision codes. Healthy, matched controls were randomly selected from the same tertiary care hospital database. STATISTICAL ANALYSIS Univariate comparisons between cases and controls were done using a two-group independent t-test for age and using Chi-square tests for the categorical variables. In order to identify possible independent predictors of sarcomas, a multiple logistic regression model was constructed using sarcoma status as the dependent variable and using, initially, all variables with a univariate P < 0.2 as independent variables. Variables were reduced in a manual stepwise manner to arrive at a final model. Statistical significance was set at P < 0.05. All analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC, USA). RESULTS A total of 425 sarcoma patients and 429 age, sex and race matched healthy controls were analyzed in this study. We found that a history of smoking and alcoholism was significantly associated with sarcomas. We also found that the history of cancer in first-degree relatives had a significant relationship. In addition, patients with sarcomas are more likely to have a history of another malignancy when compared with controls. CONCLUSIONS Smoking and alcohol are potential risk factors for sarcomas. In addition, a history of cancer in the first-degree relative is also a potential risk factor. Patients with sarcomas are likely to have a history of another malignancy when compared with controls.

A Rare Case of Metastatic Desmoplastic Small Round Cell Tumour: Diagnosis and Management

A 26-year-old male without any significant past medical history presented to the hospital with shortness of breath, cough, pleuritic chest pain, and weight loss for the past 3 months. On chest CT, he was found to have extensive mediastinal and hilar lymphadenopathy and multiple pulmonary nodules. On physical examination, a right groin mass was noted which had been slowly growing for the past 2 years. Ultrasound of the groin showed complex solid mass with internal vascular channels. CT guided biopsy of the mass showed desmoplastic small round cell tumour. His hospital course was complicated by hypoxic respiratory failure requiring emergent intubation and ICU admission where he completed one cycle of vincristine, cyclophosphamide, and doxorubicin with subsequent improvement, followed by extubation. His condition continued to improve after second cycle of chemotherapy and he was ultimately discharged in a stable condition to continue outpatient chemotherapy after a 2-month inpatient stay.

Tolosa-Hunt syndrome: an arcane pathology of cavernous venous sinus

Tolosa-Hunt syndrome, an idiopathic granulomatous inflammation of the cavernous sinus, is primarily a diagnosis of exclusion. The majority of patients present with unilateral orbital pain and features suggestive of paralysis of one or more of the cranial nerves passing through the cavernous sinus and/or superior orbital fissure. MRI of the head may show unilateral enhancement of the cavernous sinus and orbital apex. Treatment is with high-dose intravenous steroids followed by tapering oral steroids. Rapid amelioration of pain within 24–48 h supports this rare diagnosis. Resolution of neuropathies may take longer. We describe a case of a young man who presented with left periorbital pain, complete ophthalmoplaegia and ptosis of the left eye. MRI showed enhancement of the left cavernous sinus and orbital apex. High dose steroids led to complete resolution of pain, while ptosis and ophthalmoplaegia improved gradually.

Pyogenic granuloma of the gastrointestinal tract

Introduction: Pyogenic granuloma (PG) or granuloma pyogenicum is essentially a capillary hemangioma on the skin or a mucosal surface which shows an exophytic growth pattern and has a lobulated appearance. The most common sites are skin (40%) and mucosal surfaces (predominantly oral cavity, 60%). We intend to report all available cases of PG of gastrointestinal (GI) tract, diagnosed at the Henry Ford hospital, a tertiary referral center. Patients and Methods: A retrospective review of pathological database was performed on all GI biopsies in the last 10 years using diagnostic codes and pathology codes searching for PG of the GI tract. Results: A total of 23 cases of pathologically diagnosed PG was diagnosed over a 10 year period. The median age of patients was 64 with almost equal gender distribution (47.8% were males, and 52.2% were females). The most common location of PG was sigmoid colon (65.2%), esophagus (17.4%) and transverse colon (13%). PG presented as a polyp in 16 patients (69.6%). The most common indication for endoscopy in these cases was screening colonoscopy (30.4% cases). Discussion: PG of GI tract is rare. To date, only about 15-20 cases have been reported in the literature and most cases have been reported from Japan and Korea. This is the largest case series of this rare pathological lesion of the GI tract. Most cases of PG were diagnosed on an endoscopy done for an unrelated reason in our series. Hence, most cases were asymptomatic, unlike previously reported cases which were mostly associated with GI bleeding.