Intravenous Immunoglobulin-Associated Severe Hemolytic Anemia

Intravenous immunoglobulin (IVIG) is used to treat immunodeficiency conditions, neuro-immunological, infection-related, autoimmune, and inflammatory disorders and is typically well tolerated. A hematological adverse reaction such as hemolytic anemia and neutropenia is known to occur with IVIG, which is usually transient and subclinical. However, severe hemolytic anemia is known to occur in some cases. We present a case of a 66-year-old man who developed severe symptomatic hemolytic anemia after receiving IVIG for acute inflammatory demyelinating polyneuropathy (AIDP). The patient had known risk factors such as non-O blood group, high cumulative dose of IVIG, and underlying autoimmune condition, which would have put him at high risk for developing hemolytic anemia after IVIG. Therefore, it is prudent for clinicians to have increased awareness regarding the potential for severe hemolysis and closely monitor these patients with risk factors after treatments to identify this adverse reaction before more severe complications occur.

A Case of Severe Hypoxia Caused by Phenazopyridine-Induced Methemoglobinemia: A near Fatal Event from Over-the-Counter Medication Use

Methemoglobinemia is a rare blood disorder characterized by the oxidation of heme iron from ferrous (Fe²⁺) to ferric (Fe³⁺) state, which increases oxygen affinity and impairs oxygen release to the tissue causing hypoxia. It can be congenital or acquired; however, most cases are acquired and caused by exogenous substances such as medications, chemicals, and environmental substances. Phenazopyridine is an over-the-counter urinary analgesic medication commonly used for symptomatic relief of dysuria and has been reported to cause methemoglobinemia. However, only a handful of cases of phenazopyridine-induced methemoglobinemia have been reported. We present a case of an 89-year-old female who presented with severe hypoxia, shortness of breath, headache, nausea, and dizziness caused by phenazopyridine-induced methemoglobinemia. She was found to have a methemoglobin level of 21.5% and was treated with methylene blue, leading to a rapid improvement of her symptoms. She was taking one over-the-counter phenazopyridine 200 mg tablet three times daily for two weeks for her chronic dysuria. This case highlights the need to have a high index of suspicion of phenazopyridine-induced methemoglobinemia in a patient presenting with unexplained shortness of breath with a history of phenazopyridine use as it could lead to severe methemoglobinemia with hypoxia that could potentially be fatal if not promptly diagnosed.

A Rare Case of Longitudinally Extensive Transverse Myelitis Following Pfizer-BioNTech COVID-19 Vaccination with a Favourable Outcome

Introduction

mRNA COVID-19 vaccines are very safe, but rare adverse events such as transverse myelitis have been reported after COVID-19 vaccination.

Case Description

We report the case of 50-year-old man who presented with progressive lower extremity weakness, back pain and urinary retention after his second dose of the Pfizer COVID-19 vaccine. MRI of the spine revealed longitudinally extensive transverse myelitis (LETM). He recovered completely after treatment with intravenous methylprednisone and physical therapy.

Discussion

This case highlights the rare association between LETM and COVID-19 vaccines and encourages clinicians to maintain a high index of suspicion for prompt diagnosis and treatment.

LEARNING POINTS

Longitudinally extensive transverse myelitis (LETM) is rare adverse events after mRNA COVID-19 vaccination.Clinicians should maintain a high index of suspicion for prompt diagnosis of vaccine-induced transverse myelitis.Vaccine-induced LETM should show marked clinical improvement after appropriate treatment.

Unusual Case of Dehydration Leading to Severe Symptomatic Hypercalcemia

Patient: Female, 50-year-old

Final Diagnosis: Severe symptomatic hypercalcemia secondary to dehydration

Symptoms: Headache • nausea • dizziness • profound weakness

Medication: —

Clinical Procedure: —

Specialty: Endocrinology and Metabolic • General and Internal Medicine

Rhabdomyolysis and Neurological Manifestation With Progressive Weakness in a Young Adult: A Rare Extrapulmonary Presentation of Mycoplasma Pneumoniae

Mycoplasma pneumoniae (M. pneumoniae) is a common cause of community-acquired pneumonia. It has been associated with many extrapulmonary manifestations that can present even in the absence of pulmonary signs and symptoms. Rhabdomyolysis and central nervous system (CNS) manifestations are rare extrapulmonary manifestations. These are infrequently reported in adults. We present a case of a healthy 32-year-old male who initially presented with signs and symptoms of community-acquired pneumonia and was treated with antibiotics. However, he continued to have generalized malaise, night sweats, diffuse joint pain, and myalgias and was subsequently noted to have rhabdomyolysis with elevated creatine kinase (CK) and myoglobin levels. Rhabdomyolysis was attributed to M. pneumoniae based on the recent history of upper respiratory tract infection and M. pneumoniae immunoglobulin M (IgM) serology positivity along with high M. pneumoniae IgG titer. The other causes of rhabdomyolysis were diligently excluded based on patient history and laboratory and clinical data. This immune-mediated rhabdomyolysis improved with intravenous hydration, doxycycline, and prednisone therapy. However, the patient developed progressive weakness with neuropathy, which required treatment with intravenous immune globulin (IVIG). This case highlights the need to maintain a high index of suspicion for rare extrapulmonary manifestations of mycoplasma infection, which could be life-threatening or cause significant morbidity; and in cases of severe extrapulmonary manifestations, the appropriate use of immunosuppressive/immunomodulatory therapy may lead to a better outcome.

Rare case of catastrophic antiphospholipid syndrome with spontaneous intracranial haemorrhage

Catastrophic antiphospholipid syndrome (CAPS) is a rare but severe form of antiphospholipid syndrome (APS). The syndrome manifests itself as a rapidly progressive multiorgan failure that is believed to be caused by widespread micro-thrombosis. Seldom does bleeding comanifest with thrombosis. We present a patient with APS who presented with nausea, vomiting and fatigue, and rapidly progressed into multiorgan failure before being diagnosed with CAPS. The clinical course was complicated by an atraumatic intracranial haemorrhage which demanded discontinuation of anticoagulation. The patient was treated with high dose steroid, intravenous immunoglobulin, followed by weekly rituximab infusion. Although the trigger for CAPS was not obvious during her hospital stay, she was diagnosed with acute cytomegalovirus (CMV) infection soon after discharge. In this case report, we explore the differential diagnoses of CAPS, investigate the possibility of CMV infection as a potential trigger, present the therapeutic challenges of anticoagulation and discuss the emerging use of rituximab.