Supratik Rayamajhi

Reversal of Anticoagulation and Management of Bleeding in Patients on Anticoagulants.

Bleeding is the most common complication of all anticoagulants. Any bleeding patient on an anticoagulant should be risk-stratified based on hemodynamic instability, source of bleeding, and degree of blood loss. Although minor bleed may be managed with discontinuation of anticoagulant, major bleed may require transfusion of blood products and use of specific antidote. The residual effects of each anticoagulant may be monitored with distinct coagulation assay. Intravenous or oral vitamin K can reverse the effect of warfarin within 24 to 48 hours and is indicated for any bleeding, international normalized ratio of >10 or 4.5 to 10 in patients with other risk factors for bleeding. Fresh frozen plasma or prothrombin complex concentrate (PCC) may be necessary in major bleeding related to warfarin. Protamine sulfate reverses the effect of unfractionated heparin completely and of low-molecular-weight heparin (LMWH) partially. Idarucizumab has recently been approved in United States for dabigatran reversal, whereas andexanet alfa is expected to get approved in the near future for reversal of oral factor Xa inhibitors. The PCC may reverse the effect of rivaroxaban to some extent, but no data are available regarding reversal of apixaban and edoxaban. Aripazine has shown promising results to reverse the effects of LMWH, fondaparinux, and direct oral anticoagulants but is still in the developmental phase.

An Unusual Cause of Altered Mental Status in Elderly—Acute Cerebellitis: A Case Report and Review

Acute cerebellitis is a rare diagnosis found mostly in the pediatric population. The etiology, in most instances, is unknown. We describe the case of a 61-year-old woman who presented with acute mental status changes, signs of cerebellar dysfunction, and MRI findings of acute cerebellitis. A brief review of the existing literature and comparison of our case with previous reports are also presented.

Atypical Presentation of Lemierre’s Syndrome Causing Septic Shock and Acute Respiratory Distress Syndrome

Lemierres disease is a rare but life-threatening condition characterized by an oropharyngeal infection complicating with thrombophlebitis of the internal jugular vein and disseminated abscesses. We are presenting a case of a young female who initially presented with fevers, chills, sore throat, and swollen neck later developed progressively worsening shortness of breath along with sudden onset pleuritic chest pain. She then developed progressively worsening acute hypoxic respiratory failure requiring intubation and mechanical ventilation. Interval chest X-ray showed worsening bilateral effusions. She also developed septic shock requiring pressors. Blood culture showed Fusobacterium, and antibiotics were changed accordingly following which there was a clinical improvement. The diagnosis of Lemierres syndrome was then established based on her presenting age and bilateral pulmonary empyema in the setting of septicemia with Fusobacterium.

Sarcoidosis and Monoclonal Gammopathy of Undetermined Significance (MGUS): A True Association or Just a Coincidence?

Sarcoidosis is a systemic inflammatory disease characterized by the presence of noncaseating granulomas in different organs. Sarcoidosis associated with monoclonal gammopathy of undetermined significance (MGUS) is a rare finding with only 10 cases reported to date. We describe a 79-year-old male patient who presented with dry mouth for 4 months. Lip biopsy done prior to admission showed nonnecrotizing epithelioid cell granulomas. On admission, laboratory analysis was significant for elevated calcium, decreased parathyroid hormone, increased erythrocyte sedimentation rate, undetectable parathyroid hormone-related peptide (PTHrp), mildly decreased 25-hydroxyvitamin D, elevated 1,25-dihydroxyvitamin D, elevated angiotensin converting enzyme, and positive Bence Jones protein in the urine. Serum protein electrophoresis showed an elevated gamma globulin level at 38% and an IgG monoclonal gammopathy with an M-spike of 1.47. Bone marrow biopsy was consistent with MGUS. The patient showed significant improvement with steroids and was discharged with close follow-up from nephrology and oncology. Salivary gland involvement in patients with sarcoidosis is a rare finding. Our case is a valuable addition to the small number of cases described in the literature supporting an association between plasma cell disorders and sarcoidosis. Larger prospective studies are needed to determine if a true association between the two diseases exists.

Role Of Conservative Management In Emphysematous Gastritis

Emphysematous gastritis (EG) is a rare disease of the stomach that is caused by gas-forming bacteria, and it can be lethal. There have been <70 reported cases in the English literature of this disease which carries a mortality rate up to 60%. Early recognition and treatment through conservative management have been a popular and successful choice in today’s medicine. Studies have shown that surgical intervention does not confer a statistical benefit on mortality in this condition. We present another case of EG in a 33-year-old woman who was successfully managed conservatively.

Urinary Bladder Mass Due To Chronic Lymphocytic Leukaemia

A 66-year-old man was diagnosed with chronic lymphocytic leukaemia (CLL) in November 2014. At diagnosis, his lymphocyte count was 169.66×109/L (table 1). The fluorescent in situ hybridisation (FISH) panel revealed 13q deletion, but there was no evidence of 17p deletion, 11q deletion or t (11;14). He then received four cycles of bendamustine and rituximab, and at the end of the treatment complete blood count showed a lymphocyte count of 1.01×109/L (table 1), and an interval bone marrow biopsy showed only small lymphoid aggregate suggestive of partial response.1 In June 2017, his lymphocyte count was found to be elevated at 14.5×109/L (table 1). An immunophenotypic analysis of the peripheral blood demonstrated approximately 78% lymphocytes and 0.5% mature CD14-positive monocytes. A predominant monoclonal …

Renal cancer in recipients of kidney transplant

The aim of our study is to determine characteristics and outcomes of kidney cancer in renal transplant recipients. MEDLINE® database was searched in June 2015 to identify cases of kidney cancer in renal transplant recipients. We include also a new case. Descriptive statistics were used for analysis. Forty-eight (48) recipients reported in 25 papers met the eligibility criteria. The median age was 47 years (range 9-66); 27% were females. Chronic glomerulonephritis, cystic kidney disease and hypertension were common indications for renal transplant. Among donors 24% were females and the median age was 52.5 years (17-73); 62% of kidney cancers were donor-derived. The median interval between transplant and cancer diagnosis was shorter for cancer of recipient versus donor origin (150 vs. 210 days). Clear cell carcinoma was diagnosed in 17%. 25% had metastasis at diagnosis. Kidney explantation or excision was done in 90% and 84% of cases with and without metastasis respectively. The median survival was 72 months. Actuarial 1-year and 5-year survival rates were 73.4% and 55.1% respectively. Among the recipients from 7 donors who subsequently developed malignancy, 57% were dead within a year. Kidney transplant recipients have a small risk of kidney cancer, which affects younger patients and occurs within a year of transplant, likely due to immunosuppression. Whether the use of older donors may increase the likelihood needs further investigation. The presence of metastasis, explantation or excision of affected kidney and development of cancer in donors predict outcomes. The results may guide patient education and informed decision-making.

Chylothorax: A review of management options

Chylothorax is a rare condition caused by obstruction or injury to the thoracic duct leading to accumulation of chyle in the pleural cavity. A definitive guideline for management is lacking and most cases are managed with a staged care plan that moves from the least invasive options to more invasive interventions. First-line therapy consists of treatment of underlying conditions, pleural drainage to control symptoms, and dietary modifications. Surgical measures including pleurodesis and thoracic duct ligation are pursued if conservative measures are ineffective. In recent times, percutaneous image-guided interventions such as thoracic duct embolization and thoracic duct disruption are increasingly being used. These interventions have shown promising results and are used to manage patients with failed conservative therapy, high-output chylothorax, and those who cannot tolerate surgical procedures.