Stevens-Johnson Syndrome in a Patient on Concomitant Treatment with Levetiracetam and Trimethoprim/Sulfamethoxazole

BACKGROUND Trimethoprim/sulfamethoxazole and levetiracetam are commonly prescribed medications in the treatment of infections and seizures, respectively. Despite their known efficacy, each has a reputation for triggering severe and sometimes life-threatening cutaneous adverse drug reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Although the mechanism of such cutaneous adverse drug reactions cannot be fully explained, it is thought to be a type IV T cell and NK cells-mediated hypersensitivity reaction that leads to keratinocyte apoptosis and epidermal necrosis. It is also thought that cutaneous adverse drug reactions are also linked to a patient's genetic predispositions, especially the human leukocyte antigens profiles and the N-acetyl transferase 2 phenotypic variation. CASE REPORT We describe a case of Stevens-Johnson syndrome in a severely ill 51-year-old man who was treated in an outside health care facility simultaneously with Trimethoprim/sulfamethoxazole and levetiracetam. The patient presented to our Emergency Department with Stevens-Johnson syndrome believed to possibly be related to the combination of these 2 agents. CONCLUSIONS The concomitant use of Trimethoprim/sulfamethoxazole and levetiracetam might have been responsible for heightening the potential of these 2 medications to trigger an unfortunate adverse drug reaction, but no formal culprit was able to be identified and no in vivo study was performed, due to ethical considerations. Thus, through this case report we strive to increase awareness of the potential risk of simultaneously prescribing these 2 medications.

Reactive Thrombocytosis after Splenectomy in Hereditary Spherocytosis: Case Report and Literature Review

Reactive thrombocytosis after splenectomy is a feared cause of thrombosis throughout the arterial and venous system. There are many causes of splenomegaly, ranging from cirrhosis to lymphoma to hereditary spherocytosis. In this report, we will discuss a case of reactive thrombocytosis after splenectomy in a patient with hereditary spherocytosis. Splenomegaly is a relatively common finding in HD patients, causing extravascular haemolysis and thus leading to haemolytic anaemia. Splenectomy is usually considered when patients start to manifest severe symptoms such as abdominal pain, jaundice or worsening liver function tests. Our patient was a good surgical candidate and successfully underwent splenectomy but afterwards developed arterial and venous thrombosis due to reactive thrombocytosis. An extensive hypercoagulable work-up was unremarkable. The patient was started on hydroxyurea and anticoagulation with eventual improvement of platelet levels.

LEARNING POINTS

Reactive thrombocytosis can be a significant complication after splenectomy and can range from mild (500,000-700,000/mm³), to moderate (700,000-900,000/mm³), severe (>900,000/mm³) and very severe thrombocytosis (>1,000,000/mm³).The use of low-dose hydroxyurea in patients with very severe thrombocytosis can reduce the platelet count to safe levels, and thus, the risk of developing thrombosis.

A Case of Pyelonephritis in an Anuric Patient with End-Stage Renal Disease on Hemodialysis

Urinary tract infections are common sources of infections requiring antibiotic use worldwide. Chronic kidney disease (CKD) patients, especially those with minimal urine output are challenging when it comes to antibiotic stewardship given the scarcity of cases in the literature. It is further complicated by the fact that end-stage renal disease (ESRD) patients are found to have asymptomatic pyuria and its clinical significance for bacterial infection is yet to be determined. In this case, we report a patient who presented with non-specific symptoms including fever, cough, chills, diarrhea, nausea and was found to have left-sided perinephric stranding on CT scan of the abdomen. The patient also had a fever of 104.6 F which we attributed to left-sided pyelonephritis given the high sensitivity of such findings on CT scan. In this report, we explored the literature for the incidence and management of pyelonephritis in ESRD patients who are anuric.

Acute Pancreatitis Induced Splenic Vein Thrombosis

Acute inflammation of the pancreas, known as pancreatitis, can result in many complications ranging from acute distress respiratory syndrome to pancreatic necrosis. A relatively common vascular complication of pancreatitis is splenic vein thrombosis (SVT) due to intimal inflammation leading to platelet aggregation and thrombosis. The management of SVT with regard to anticoagulation (AC) might appear to be perplexing at first given the recommendation to withhold any sort of AC. Research studies have shown that these patients have an increased risk of gastrointestinal bleeding without AC. In this report, we discuss a case of hypertriglyceridemia-induced pancreatitis. During hospitalization, our patient complained of worsening abdominal pain with objective fevers and leukocytosis in which CT scan of the abdomen was significant for hemorrhagic pancreatitis with necrosis, acute SVT, and splenomegaly. The patient was managed conservatively with IV fluids, pain relief medications, and antibiotics. 

Acute Renal Failure in a Patient With Severe Acute Respiratory Syndrome Coronavirus 2

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious viral pathogen with high morbidity and mortality rate. The infection affects multiple organ systems leading to systemic organ failure. There is an increased incidence of acute kidney injury (AKI) in patients who become critically ill. In the critical care setting, the incidence of AKI has been variable amongst different studies. Patients with acute kidney injury who progress to renal replacement therapy are associated with worse outcomes. We describe a case of a 42-year-old male who presented with hypoxemic respiratory failure secondary to SARS-CoV-2 associated pneumonia. The patient was initially managed with the nasal cannula and then required high flow nasal cannula with worsening hypoxemic respiratory failure, requiring invasive mechanical ventilation. On top of worsening respiratory status, the patient developed new onset renal failure requiring hemodialysis.