Syed Hassan

A patient with Parkinson's disease benefits from spinal cord stimulation.

We present a case of a 43-year-old woman with a history of Parkinsons disease and chronic neuropathic pain secondary to trauma. She was implanted with a spinal cord simulator to relieve her persistent intractable pain. After the implantation of the device the patient not only was relieved of her neuropathic pain but also found significant improvement in her Parkinson symptoms.

Currently recommended BK virus (BKV) plasma viral load cutoff of ≥4 log10/mL underestimates the diagnosis of BKV-associated nephropathy: a single transplant center experience.

BK virus (BKV)‐associated nephropathy (BKVAN) is a major cause of renal dysfunction and graft loss in renal transplant recipients. Monitoring plasma BK viral load (BKVL) is the recommended screening tool to predict BKVAN. American Society of Transplantation (AST) guidelines define a BKVL of ≥4 log10/mL (10,000 copies) as presumptive BKVAN and recommend reduction in immunosuppression. We evaluated the clinical sensitivity of the quantitative BKV DNA assay in predicting risk for BKVAN using the AST‐recommended BKVL cutoff.

Thrombosis in VonWillebrand disease.

OBJECTIVE To date, only a few case studies have reported occurrence of thrombosis in patients with VonWillebrand disease (VWD). No studies have looked at its incidence in this patient population. The aim of this study was to test our hypothesis that decreased VonWillebrand factor (VWF) levels confer a protective effect on arterial and venous thrombosis. METHODS This is a retrospective cohort study including patients (n=350) with the ICD-9 code of VWD who were identified from our hospital database over a period of 25 years, out of which 198 patients were included in the final sample. A parallel control sample without VWD matched for age, sex, hypertension, hyperlipidemia, atrial fibrillation and diabetes mellitus was also obtained from the hospital database. The primary outcomes were incidence of diagnosis of symptomatic arterial and venous thrombosis. The results were computed using multivariate conditional logistic regression analysis and proportions were compared using McNemers Chi - square test. RESULTS Out of 198 patients (mean age 44.2 ± 17.5, women 72%) with VWD, 170 (86%) were VWD type 1, 21 (10%) were type 2 and 7 (3%) were type 3. VWD was found to be an independent protective predictor from arterial thrombosis (OR 0.28, 95% CI 0.14-0.54, p<0.0001), more so in CAD (OR 0.28, 95% CI 0.12-0.64, p=0.002) than in CVD (OR 0.28, 95% CI 0.10-0.77, p=0.01). However this was not the case in venous thrombosis (p=0.42). CONCLUSION In a population of relatively younger individuals with VWD, our study suggests a reduced incidence of arterial thrombosis but not of venous thrombosis. This brings up the possibility that there could be other pathways or factors involved in arterial and venous thrombosis. To our knowledge, this is the first large observational study that has provided insight into the thrombotic disease in this group of patients.

Pulmonary Mucormycosis: An Emerging Infection

Mucormycosis is a rare, but emerging, life-threatening, rapidly progressive, angioinvasive fungal infection that usually occurs in immunocompromised patients. We present a case of pulmonary mucormycosis in a diabetic patient who was on chronic steroid therapy for ulcerative colitis. Early recognition of this diagnosis, along with aggressive management, is critical to effective therapy and patient survival. The delay in diagnosis of this rapidly progressive infection can result in mortality.

Heparin‐induced thrombocytopenia: is it a graft‐threatening complication?

Heparin‐induced thrombocytopenia (HIT), a prothrombotic complication of heparin therapy, can lead to serious thromboembolic events and cause significant morbidity and mortality. We aim to study the prevalence of HIT in the transplant population at our institute. This is a retrospective, single‐center study which looked into the transplant database over a 25‐year period. In patients with clinical suspicion of HIT, the 4T score was used, and laboratory tests such as ELISA HIT antibody and functional serotonin release assay, along with clinical manifestation of thromboembolic events were reviewed. Medical records of 2800 patients who underwent transplantation from January 1985 to December 2010 were reviewed. HIT antibody assay was performed in 262 patients from this group in which HIT was suspected. Of these, only 48 patients were HIT antibody positive along with moderate to high 4T score. The mean 4T score was 6.75 ± 1.4. Thrombotic complications were seen in 11 patients, with the highest in cardiac transplant recipients. Direct thrombin inhibitor (DTI) therapy was used in only eight patients who had thrombotic event. No other complications or mortality was reported in any of the HIT antibody‐positive transplant patients. To our knowledge, this is the first study of its kind that has shown very low incidence of HIT in the transplant population except for in cardiac transplant recipients.

Congenital von Willebrand's disease and clinical hypothyroidism

Data from case reports and systematic reviews suggest an association of Hypothyroidism and Acquired von Willebrands syndrome. It is not known if congenital von Willebrands disease is associated with hypothyroidism in a similar way. The aim of this study was to identify the association of congenital von Willebrands disease (VWD) with clinical hypothyroidism. A total of 350 cases of congenital VWD were initially screened from our institution database from 1985 to 2010. A careful review of patient records was carried out to see if patients truly had congenital VWD and coexisting clinical hypothyroidism. Patients with uncertain diagnoses or other bleeding disorders were excluded, leading to 197 patients remaining in the final sample. A random age‐ and sex‐matched parallel control group was also obtained from the hospital database. Of 197 patients (mean age 43.8 ± 17.5 years, women 72%) of congenital VWD, 32/197 (16%) were diagnosed with clinical hypothyroidism, while only 11/197 (5.6%) of the matched controls were clinically hypothyroid. Univariate and multivariate analysis demonstrated that VWD was an independent predictor of developing clinical hypothyroidism (OR 3.45; 95% CI 1.65–7.22, P = 0.001). The proportion of patients diagnosed with clinical hypothyroidism was more in the VWD group (P < 0.0001). Our analysis shows a strong association of clinical hypothyroidism in patients with congenital VWD, but future studies will be required to delineate a pathological mechanism. In our opinion, clinicians should consider checking thyroid function in the newly diagnosed and established cases of congenital VWD.

Celiac Artery Compression Syndrome

Celiac artery compression syndrome is a rare disorder characterized by episodic abdominal pain and weight loss. It is the result of external compression of celiac artery by the median arcuate ligament. We present a case of celiac artery compression syndrome in a 57-year-old male with severe postprandial abdominal pain and 30-pound weight loss. The patient eventually responded well to surgical division of the median arcuate ligament by laparoscopy.

Metastatic squamous cell carcinoma in a bone marrow transplant recipient

We report a case of 53year old female with history of acute myelogenous leukemia, for which she underwent allogeneic peripheral blood stem cell transplant; her course was complicated by chronic graft versus host disease. Seven years later she presents with squamous cell carcinoma of the skin which metastasize to her heart. Here, in this case we tend to highlight the aggressive nature of the squamous cell carcinoma in an immunocompromised individual.

Treating symptomatic coronary artery disease in patients with Von Willebrand disease

There is limited data on the occurrence of coronary artery disease (CAD) in patients with Von Willebrand disease and the literature is even scarce on their management. We at our institute reviewed the medical records of 198 patients with Von Willebrand disease over a period of 15years, of which 6 were found to have symptomatic CAD. Acute coronary syndrome was noted in 3 patients while the remaining 3 had stable angina. Cardiac catheterization showed that left main coronary artery was the culprit vessel in all of these patients. In terms of management, stents were placed in 3 patients, two of them underwent coronary artery bypass grafting, and the remaining one patient was medically managed. Aspirin, and in some patients clopidogrel, was well tolerated with minimal side effects.

Cryofibrinogenaemia: not just skin deep.

A Caucasian woman in her 60s with a history of rheumatoid arthritis presented to our institution complaining of skin ulceration. Her initial course was complicated by superinfection and sepsis until a diagnosis of cryofibrinogenaemia was finally established. Cryofibrinogenaemia remains as an under-recognised entity in part, because it can mimic other causes of skin ulcerations. In addition, its diagnosis can be challenging because of the particular handling techniques required of lab specimens. This case exemplifies some of the diagnostic and treatment challenges encountered while managing the patient with cryofibrinogenaemia.