Sujith V. Cherian

Diabetic ketoacidosis complicated by generalized venous thrombosis: a case report and review.

Venous thromboembolism is a rarely described complication of diabetic ketoacidosis (DKA). We describe a 21-year-old male patient with poorly controlled type 1 diabetes mellitus who was admitted with DKA, presumably secondary to noncompliance, whose clinical picture was complicated by generalized thrombosis involving multiple venous locations including renal vein, pulmonary vasculature, external iliac and common iliac veins. The patient had no family history of any coagulation disorders and a hypercoagulabilty work-up remained negative. The patient was subsequently anticoagulated with heparin and discharged home on warfarin. To the best of our knowledge, this is the first reported case of multiple venous thromboses occurring as a complication of DKA with no other risk factors. We also reiterate that although rare, venous thrombosis should always be considered as a potential complication of DKA.

Carfilzomib: a rare cause of posterior reversible encephalopathy syndrome.

Dear Editor, Posterior reversible encephalopathy syndrome (PRES) is an acute neurologic syndrome that has been associated with several clinical conditions and drug exposures including immunosuppressive medications. An association between PRES and early-generation proteasome inhibitors (i.e., bortezomib), which are indicated for treatment of refractory multiple myeloma, has also been made [1–5]; however, there have been only two previously reported cases of carfilzomib-associated PRES and we present the third. A 61-year-old Caucasian woman with relapsed multiple myeloma (IgG/lambda light chain restricted), end-stage renal disease on scheduled hemodialysis, who had been initiated on treatment with 28-day cycles of carfilzomib (27 mg/m) and dexamethasone (40 mg), presented with 1-day history of headache, back pain, jerky movements, and confusion. She was initiated on a second cycle of carfilzomib/dexamethasone 5 days before. On initial examination, patient was afebrile, hypertensive (BP 212/136 mmHg), and tachycardic (135 bpm). She was confused, oriented only to self, did not follow commands, and moved all extremities spontaneously and symmetrically. Later she had a complex seizure for which antiepileptics were administered. Labs revealed stable chronic anemia (hemoglobin 7.9 g/dL), thrombocytopenia (platelets 38 K/uL), increased creatinine (9.5 mg/dL), urea nitrogen (83 mg/dL), and mild hyper-ammonia (20 umol/L). Infectious workup and urine drug screen were negative on further analysis and normal immunoglobulin counts ruled out hyperviscosity syndrome. A non-contrast CT of the head was unremarkable and initial EEG demonstrated moderate to severe generalized encephalopathy, without epileptiform activity. The patient’s mental status continued to deteriorate; therefore, she was transferred to the ICU where emergent dialysis was started for possible uremic encephalopathy. Despite dialysis and normalization of her blood pressure, the patient continued to be altered. A prolonged EEG revealed severe generalized encephalopathy and left temporal periodic lateralized epileptiform discharges. MRI of the brain revealed T2 hyperintensities in the parieto-occipital and cerebellar lobes suggestive of PRES (Fig. 1). The patient was ultimately diagnosed with PRES, likely associated with her recent carfilzomib treatment. She returned to her baseline neurological status with supportive treatment, within 7 days, during which her blood pressure remained adequately controlled. She was discharged without further episodes of confusion or complex seizures, has continued follow-up in clinic for her multiple myeloma, and was started on a new chemotherapy regimen: daratumumab, pomalidomide, and dexamethasone, without additional neurological sequelae. Our case represents a classical presentation, resembling those previously reported in association with both * Nurit Katz-Agranov Nurit.S.Katz@uth.tmc.edu

Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire

Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m2 (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

Hypercalcemia: An Unusual Manifestation of Uterine Leiomyoma

We present a case of hypercalcemia in a 79-year-old female likely secondary to uterine leiomyoma. To the best of our knowledge, hypercalcemia due to a benign tumor has only been described in five cases. Of these above five cases, uterine leiomyoma was thought to be the cause of hypercalcemia in three cases.

Thoracic splenosis mimicking pleural mass: the importance of clinical history

A 45-year old man with obesity, type 2 diabetes, hypertension and 30-pack-year smoking history presented with intermittent, severe, sharp, left sided chest pain, associated with dizziness for 5 days. A computed-tomography angiography of the chest ruled out pulmonary embolism, but showed multiple pleural-based nodules along the left diaphragmatic pleura (Figure 1A, arrow). Given his smoking history, malignancy was considered a high probability, and …

Current Concepts in Pathogenesis, Diagnosis, and Management of Smoking-Related Interstitial Lung Diseases

&NA; Tobacco exposure results in various changes to the airways and lung parenchyma. Although emphysema represents the more common injury pattern, in some individuals, cigarette smoke injures alveolar epithelial cells and other lung cells, resulting in diffuse infiltrates and parenchymal fibrosis. Smoking can trigger interstitial injury patterns mediated via recruitment and inappropriate persistence of myeloid and other immune cells, including eosinophils. As our understanding of the role of cigarette smoke constituents in triggering lung injury continues to evolve, so does our recognition of the spectrum of smoking‐related interstitial lung changes. Although respiratory bronchiolitis‐interstitial lung disease, desquamative interstitial pneumonia, pulmonary Langerhans cell histiocytosis, and acute eosinophilic pneumonia have a well‐established association with tobacco use, its role and impact on idiopathic pulmonary fibrosis, combined pulmonary fibrosis and emphysema, and connective tissue disease‐related interstitial lung diseases is still ambiguous. Smoking‐related interstitial fibrosis is a relatively newly appreciated entity with distinct histopathologic features but with unclear clinical ramifications. Increased implementation of lung cancer screening programs and utilization of CT scans in thoracic imaging have also resulted in increased identification of “incidental” or “subclinical” interstitial lung changes in smokers, the ensuing impact of which remains to be studied.

Intravenous immunoglobulin-associated renal failure in a patient with post-transfusion purpura.

Intravenous immunoglobulin (IVIG), initially developed for immunodeficiency disorders, has now been used for multiple autoimmune diseases and infections. These are generally well tolerated, with few adverse effects. Acute kidney injury has been described in very rare instances. We report an interesting case of a 59-year-old African American male with a pertinent history of diabetes mellitus, hypertension, endocarditis, and peripheral vascular disease, who was diagnosed with post-transfusion purpura. He was then treated with IVIG and subsequently developed an acute worsening of renal function in a time span of 3 days. The etiology remained elusive even after an extensive workup. Renal biopsy was done finally, which showed findings suggestive of osmotic nephropathy that was traced to the sucrose used as a stabilizing agent in the IVIG. In light of the increasing use of IVIG, it is therefore highly recommended that clinicians are well aware of this side effect of IVIG.

Anticoagulant-resistant thrombophilia in a patient with polycythemia vera: a case report.

Mechanical valve thrombosis is a rare condition in an adequately anticoagulated patient in the absence of underlying thrombophilia. We report a case of a 76-year-old male with mechanical prosthetic mitral valve thrombosis as the presenting feature of polycythemia vera. The patient was treated with thrombolysis at the time of acute presentation and subsequently maintained on low molecular weight heparin, low-dose aspirin, phlebotomy and hydroxyurea. Hemoglobin, leucocytosis and platelet count were controlled for almost 4 years after which the patient suffered a second, fatal episode in the setting of therapeutic anti-Xa level. This case report highlights the thrombotic risks associated with polycythemia vera. The proposed mechanisms of hypercoagulability in polycythemia vera are reviewed. To the best of our knowledge, mechanical valve thromboses as the presenting feature of polycythemia vera has not been reported previously.

Vasculitis due to levamisole-adulterated cocaine

A 68-year-old woman presented with skin lesions for 1 week. She reported similar lesions 6 months before, which had resolved within a few weeks. Physical examination showed haemorrhagic lesions over forearms and face with bullae (figure 1A,B). Laboratory tests revealed pancytopaenia with neutropaenia. Antinuclear antibody, perinuclear antineutrophil cytoplasmic antibody (p-ANCA), antiproteinase-3 (anti-PR3) and antimyeloperoxidase (anti-MPO) antibodies were positive with high titres. Complement levels were normal. Cryoglobulin and rheumatoid factor were negative. Urine toxicology screen was positive for cocaine. Skin biopsy showed leukocytoclastic …

Primary pulmonary lymphoproliferative neoplasms

Pulmonary lymphoproliferative neoplasms are rare lung tumors and account for <1% of all lung tumors. Among them, primary pulmonary lymphomas (PPL) constitute the majority, which include Non-Hodgkins lymphoma (NHL) that comprise of mucosa-associated lymphoid tissue lymphoma, diffuse large B-cell lymphomas and other rare types of NHL and lymphomatoid granulomatosis. HL, which arises secondary to contiguous spread from the mediastinum, is the rarest type of PPL. Other entities described within the umbrella of pulmonary lymphoproliferative neoplasms include pleural lymphomas and posttransplant lymphoproliferative disorders (PTLD) – which occurs in the poststem cell and organ transplant patients. These neoplasms although rare, have a favorable prognosis, which does not depend on disease resectability. Moreover, with its nonspecific presentation, diagnosis is challenging, which often leads to delayed diagnosis or misdiagnosis in many cases. Therefore, knowledge of this entity is important for the practicing pulmonologist. This review article aims to describe the clinical presentation, diagnosis and management of primarily the entities within PPL, as well as pleural lymphomas and PTLD.