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Fraga C, Losa A, Cascais I, Garrido C, Lachado A, Couto Guerra I, Bandeira A, Cleto E, Costa E. Severe Hemolytic Anemia: Atypical Presentation of Cobalamin Deficiency. J Pediatr Hematol Oncol 2024; 46:172-174. [PMID: 38408112 PMCID: PMC10956652 DOI: 10.1097/mph.0000000000002829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/18/2024] [Indexed: 02/28/2024]
Abstract
Two severe cases of hemolytic anemia are described in different pediatric age groups, both linked to severe cobalamin deficiency from distinct causes. The first case refers to an exclusively breastfed infant with vitamin deficit secondary to maternal impaired absorption. Apart from the neurological deficits present at diagnosis, he also presented with infantile epileptic spasms syndrome a few months after treatment while having normal cobalamin serum levels. The second case refers to an adolescent with long-term inadequate intake. The occurrence of severe hemolytic anemia in cobalamin deficiency is exceptionally rare.
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Affiliation(s)
- Carolina Fraga
- Department of Pediatrics, Centro Materno-Infantil de Norte, Centro Hospitalar Universitário de Santo António (CMIN, CHUdSA)
| | | | | | | | | | | | - Anabela Bandeira
- Center for Inborn Metabolic Diseases, CMIN-CHUdSA, Porto, Portugal
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Jiang L, Chen S. Case report: A case of novel homozygous LRBA variant induced by chromosomal segmental uniparental disomy - genetic and clinical insights. Front Immunol 2024; 15:1351076. [PMID: 38504982 PMCID: PMC10948553 DOI: 10.3389/fimmu.2024.1351076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/20/2024] [Indexed: 03/21/2024] Open
Abstract
Objective The study aims to report a rare case of a novel homozygous variant in the LRBA gene, originating from uniparental disomy of paternal origin. This case contributes new clinical data to the LRBA gene variant database. Methods The study details the case of a 2-year-old child diagnosed in May 2023 at our center with a homozygous LRBA gene variant. Detailed clinical data of the patient were collected, including whole-exome sequencing of peripheral blood mononuclear cells, with parental genetic verification. Results The child presented with recurrent respiratory infections and chronic neutropenia, progressing to pancytopenia. Imaging showed splenomegaly and enlarged lymph nodes in the axillary and abdominal regions. Peripheral blood lymphocyte count revealed reduced B cells and NK cells. Elevated cytokine levels of IFN-α and IFN-r were observed. Whole-exome sequencing revealed a nonsense homozygous variant in the LRBA gene, specifically c.2584C>T (p.Gln862Ter). The father exhibited a heterozygous variant at this locus, while no variant was found in the mother. Sample analysis indicated characteristics of uniparental disomy. According to the guidelines of the American College of Medical Genetics and Genomics (ACMG), this variant is preliminarily classified as "Likely pathogenic". Currently, there are no reports in academic literature regarding this specific variant site. Conclusion LRBA gene variants can lead to a rare inborn error of immunity disease. The c.2584C>T (p.Gln862Ter) variant in exon 22 of the LRBA gene is a newly identified pathogenic variant, and the homozygous variant caused by uniparental disomy is exceedingly rare. This case represents the second global report of an LRBA gene function loss due to uniparental disomy abnormalities.
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Affiliation(s)
| | - Sen Chen
- Hematology Department, Tianjin Children’s Hospital (Children’s Hospital, Tianjin University), Tianjin Key Laboratory of Birth Defects for Prevention and Treatment, Tianjin, China
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Imataki O, Uemura M. Gelatinous bone marrow with vivid fatty cells. Oxf Med Case Reports 2024; 2024:omae013. [PMID: 38532751 PMCID: PMC10962228 DOI: 10.1093/omcr/omae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/10/2024] [Indexed: 03/28/2024] Open
Abstract
We treated a 78-year-old Japanese man with gastric diffuse large B cell lymphoma. The patient received three courses of chemotherapy and involved-field local radiation therapy to the stomach. Three years after chemotherapy, the patient become sick with anorexia and pancytopenia. He was cachexic, however, levels of vitamin B12, folate, zinc, and copper were normal. His bone marrow revealed focal eosinophilic deposit characterized by mixture of vivid atrophic fatty cells, which was pathologically diagnosed as gelatinous bone marrow. The patient's gelatinous marrow was characterized by CD68-stained vivid atrophic fatty tissue. We found that this finding is a possible alternative marker for gelatinous marrow.
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Affiliation(s)
- Osamu Imataki
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Makiko Uemura
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
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Khan S, Yetiskul E, Khan MWZ, Chavez Reyna G, Matra A, Khattar G, Odaimi MA. Aplastic Anaemia Associated with Bendamustine Therapy - A Rare Side Effect. Eur J Case Rep Intern Med 2024; 11:004339. [PMID: 38455694 PMCID: PMC10917404 DOI: 10.12890/2024_004339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction During treatment for malignant lymphoma, cytopenia can develop for several reasons. This can range from mild cytopenias leading to infection and bleeding to full-blown drug-induced aplastic anaemia. While aplastic anaemia affects individuals of all genders and ages, here, we describe aplastic anaemia after chemotherapy exposure to bendamustine in a 65-year-old female with non-Hodgkin's lymphoma. Case description A 65-year-old woman with recurrent indolent marginal zone lymphoma and post-chemotherapy with bendamustine and rituximab, presented with a neutropenic fever and was admitted with a leading diagnosis of sepsis. In the previous two weeks, the patient required regular transfusions of packed red blood cells and platelets and maintained a daily ZARXIO® regimen. Laboratory results revealed pancytopenia, and broad-spectrum antibiotics (cefepime/vancomycin) were given. The patient was subsequently admitted to the hospital under the care of the haematology/oncology team and was ultimately diagnosed with aplastic anaemia, likely as a consequence of bendamustine chemoimmunotherapy. She elicited a positive response to the triple immunosuppressive therapy (IST) regimen (two immunotherapeutic agents plus one anti-thymocyte globulin (ATG), after which her cell counts returned to normal. Conclusions This case underscores the importance of recognising haematologic complications linked to bendamustine and advocates for further research to increase the understanding among healthcare professionals of drug-induced aplastic anaemia. Bendamustine can cause severe autoimmune haemolytic anaemia and aplastic anaemia and may require multiple transfusions and a multidrug regimen for treatment. The use of ATG as a therapeutic intervention is appropriate because it has been effective in treating aplastic anaemia. LEARNING POINTS Bendamustine can cause severe autoimmune haemolytic anaemia and aplastic anaemia, a side effect which has rarely been reported but is of significant clinical importance.Drug-induced aplastic anaemia is a complex, potentially devastating consequence of treating blood cancers and is a relatively unexplored area that requires further understanding.Anti-thymocyte globulin is effective in treating bendamustine-induced aplastic anaemia as it degrades lymphocytes that destroy the bone marrow.
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Affiliation(s)
- Salman Khan
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, NY, USA
| | - Ekrem Yetiskul
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, NY, USA
| | | | - Gabriel Chavez Reyna
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, NY, USA
| | - Amanda Matra
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, NY, USA
| | - Georges Khattar
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, NY, USA
| | - Marcel A. Odaimi
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, NY, USA
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Brito MT, Amador AF, Moço Coutinho R, Ribeiro A, Almeida JS. Human Herpesvirus-8 (HHV-8)-Positive Human Immunodeficiency Virus (HIV)-Negative Multicentric Castleman Disease With a Fulminant Course. Cureus 2024; 16:e54350. [PMID: 38500919 PMCID: PMC10945459 DOI: 10.7759/cureus.54350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/20/2024] Open
Abstract
Multicentric Castleman disease (MCD) is a poorly understood, heterogeneous lymphoproliferative disorder with benign hyperplastic lymph nodes and systemic inflammatory symptoms. Human herpesvirus-8 (HHV-8) may be associated with MCD, whether or not the patient is infected with the human immunodeficiency virus (HIV). A 74-year-old man presented with anaemia, thrombocytopenia and bilateral axillary adenomegaly of unknown origin. The patient was admitted to the hospital two years ago with clinical signs of weight loss, asthenia, anorexia and a maculopapular rash on the trunk and back. Blood analysis showed pancytopenia (haemoglobin 7.7 g/dL, leucocytes 2.55 x 109/L and platelets 41 x 109/L), elevated acute phase reactants (such as C-reactive protein, erythrocyte sedimentation rate, ferritin and fibrinogen), hypoalbuminemia and hypergammaglobulinemia, and HIV serology was negative. Thoracic, abdominal and pelvic axial tomography showed generalised lymphadenopathy. The bone marrow biopsy showed only reactive changes, and the histology of an excisional biopsy of the adenopathy was consistent with the plasmablastic variant of MCD associated with HHV-8. The HHV-8 viral load was 3.8 x 104 copies/mL (4.5 log). He was started on prednisolone 60 mg/day and rituximab. He had a poor response to therapy, despite a reduction in the HHV-8 viral load, with clinical deterioration, transfusion-dependent anaemia and progression to multi-organ dysfunction leading to death three weeks after starting treatment. Our patient had a fulminant course of MCD despite treatment with rituximab. Further studies are needed to validate the different treatment modalities and to better understand the prognosis of this disease.
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Affiliation(s)
- Maria Teresa Brito
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | | | | | - Ana Ribeiro
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Jorge S Almeida
- Medicine, Faculdade de Medicina da Universidade do Porto (FMUP), Porto, PRT
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
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Mitani H, Chosa K, Kondo S, Fukumoto W, Kajiwara K, Yoshimatsu R, Matsumoto T, Yamagami T, Awai K. Perioperative proximal splenic artery embolization in cirrhotic patients with splenomegaly. MINIM INVASIV THER 2024; 33:35-42. [PMID: 37909461 DOI: 10.1080/13645706.2023.2275652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION The purpose of this study was to determine the effect of proximal splenic artery embolization (SAE) in cirrhotic patients with splenomegaly who underwent surgical laparotomy. MATERIAL AND METHODS This retrospective observational study included 8 cirrhotic patients with splenomegaly. They underwent proximal SAE before- (n = 6) or after (n = 2) laparotomy. Vascular plugs or coils were placed in the proximal splenic artery. The diameter of the portal vein and the splenic volume were recorded. Clinical outcome assessments included platelet counts, the model for end-stage liver disease (MELD) score, and complications. RESULTS After embolization, the portal venous diameter was significantly smaller (pre: 13.6 ± 2.7 mm, post: 12.5 ± 2.3 mm, p = 0.023), the splenic volume was significantly decreased (pre: 463.2 ± 145.7 ml, post: 373.3 ± 108.5 ml, p = 0.008) and the platelet count was significantly higher (pre: 69.6 ± 30.8 × 103/μl, post: 86.8 ± 27.7 × 103/μl, p = 0.035). Before embolization, the median MELD score was 12; after embolization, it was 11 (p = 0.026). No patient developed post-treatment complications after embolization. CONCLUSIONS The reduction of hypersplenism by perioperative proximal SAE may be safe and reduce the surgical risk in cirrhotic patients with splenomegaly.
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Affiliation(s)
- Hidenori Mitani
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Keigo Chosa
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shota Kondo
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Wataru Fukumoto
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kenji Kajiwara
- Department of Diagnostic Radiology, National Hospital Organization Kure Medical Center, Hiroshima, Japan
| | - Rika Yoshimatsu
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Tomohiro Matsumoto
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Takuji Yamagami
- Department of Diagnostic and Interventional Radiology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kazuo Awai
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
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Iyengar VV, Chougule A, Gowri V, Taur P, Bodhanwala M, Desai MM. Pediatric Pancytopenia and Monosomy 7: A Case Report of SAMD9L-Associated Disease. J Clin Immunol 2024; 44:43. [PMID: 38231353 DOI: 10.1007/s10875-023-01650-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Affiliation(s)
- Vaishnavi V Iyengar
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Akshaya Chougule
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Vijaya Gowri
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Prasad Taur
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Minnie Bodhanwala
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Mukesh M Desai
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, Maharashtra, 400012, India.
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Yu S, Yuan H, Cao Y. Caroli disease combined with Banti syndrome in a woman: a case report. J Int Med Res 2024; 52:3000605231221088. [PMID: 38190840 PMCID: PMC10775735 DOI: 10.1177/03000605231221086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/24/2023] [Indexed: 01/10/2024] Open
Abstract
Caroli disease is a rare congenital malformation that predisposes to segmental cystic dilatation of the intrahepatic bile ducts. Banti syndrome is characterized by persistent splenomegaly due to chronic congestion, resulting in a low hematocrit and ultimately leading to pancytopenia. In this report, we describe a 29-year-old woman who presented with a >20-year history of hepatitis B surface antigen positivity and a >1-year history of recurrent fatigue and malaise. On examination, the patient had abdominal distension with marked splenomegaly (7 cm below the ribs) and ascites with tenderness of the abdominal muscles to palpation. A complete blood count showed a low white blood cell count, red blood cell count, and hemoglobin concentration. During the course of treatment, the patient developed multiple symptoms of pancytopenia and concomitant splenomegaly, and she was discharged after total splenectomy with good recovery. The combination of Banti syndrome and Caroli disease results in severe symptoms of portal hypertension.
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Affiliation(s)
- Shian Yu
- Department of General Surgery, Nanchang University Affiliated Infectious Diseases Hospital, Nanchang, China
| | - Hang Yuan
- Department of General Surgery, Nanchang University Affiliated Infectious Diseases Hospital, Nanchang, China
| | - Yong Cao
- Department of General Surgery, Nanchang University Affiliated Infectious Diseases Hospital, Nanchang, China
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Meftah N, Sedaghat S, Rabizadeh S, Seifouri S, Nasirimeh K, Nakhjavani M. Graves' disease with pancytopenia: A rare case report. Clin Case Rep 2024; 12:e8312. [PMID: 38188850 PMCID: PMC10769897 DOI: 10.1002/ccr3.8312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 07/31/2023] [Accepted: 11/11/2023] [Indexed: 01/09/2024] Open
Abstract
Key Clinical Message In this case report we describe a patient with Grave's disease (GD) who was first diagnosed with pancytopenia and did not have any typical symptoms of GD. His hematologic abnormalities were alleviated after treatment with an anti-thyroid drug. Hence, in patients with pancytopenia, GD should also be considered. Abstract A variety of hematologic abnormalities can be seen in Graves' disease (GD), however; here, we describe a patient with GD and a very rare complication; pancytopenia. His hematologic abnormalities and clinical status were alleviated after treatment with an anti-thyroid drug. Hence, in patients with pancytopenia and normal bone marrow examination, GD should also be considered.
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Affiliation(s)
- Neda Meftah
- Department of Internal Medicine, School of MedicineBabol University of Medical SciencesBabolIran
| | - Sadegh Sedaghat
- Department of Internal Medicine, School of MedicineBabol University of Medical SciencesBabolIran
| | - Soghra Rabizadeh
- Endocrinology and Metabolism Research Center (EMRC)Vali‐Asr HospitalTehran University of Medical SciencesTehranIran
| | - Sara Seifouri
- Endocrinology and Metabolism Research Center (EMRC)Vali‐Asr HospitalTehran University of Medical SciencesTehranIran
| | - Khatereh Nasirimeh
- Department of Internal Medicine, School of MedicineBabol University of Medical SciencesBabolIran
| | - Manouchehr Nakhjavani
- Endocrinology and Metabolism Research Center (EMRC)Vali‐Asr HospitalTehran University of Medical SciencesTehranIran
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Hosseini E, Shahbazi F. Methotrexate-induced Severe Pancytopenia in a Patient with Rheumatoid Arthritis: A Case Report and Review of Literature. Curr Drug Saf 2024; 19:224-235. [PMID: 37194235 DOI: 10.2174/1574886318666230516115737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/15/2023] [Accepted: 04/03/2023] [Indexed: 05/18/2023]
Abstract
Toxicity associated with low doses of methotrexate (MTX) is low, but it may be fatal. Bone marrow suppression and mucositis are among the common side effects of low dose MTX toxicity. Different risk factors have been reported for toxicities associated with low doses of MTX, including accidental use of higher doses, renal dysfunction, hypoalbuminemia, and polypharmacy. In this paper, we present a female patient who had mistakenly used 7.5 mg of MTX daily instead of the same dose of MTX on Thursday and Friday. She was presented with mucositis and diarrhea to the emergency department. Moreover, we searched the databases Scopus and PubMed for available studies and case reports on toxicities associated with MTX dosing errors. The most frequently observed toxicities included gastrointestinal lesions, nausea, vomiting, skin lesions, and bone marrow suppression. Leucovorin, hydration, and urine alkalinization were among the most frequently used treatments. Finally, we summarize the data on the toxicities of low doses of MTX in different diseases.
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Affiliation(s)
- Elham Hosseini
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Foroud Shahbazi
- Department of Clinical Pharmacy, School of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Khalid F, Gaddameedi SR, Al-Alwan A, Bader H, Du D, Meghal T. The Outcome of Aplastic Anaemia Associated with Terbinafine Therapy. Eur J Case Rep Intern Med 2023; 11:004142. [PMID: 38223274 PMCID: PMC10783452 DOI: 10.12890/2023_004142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 01/16/2024] Open
Abstract
Onychomycosis (OM), a widespread fungus that affects the toenails and/or fingernails, causes a large amount of morbidity and is very frequent in the general population. The best treatment is systemic antifungals. Terbinafine is a potent antifungal drug that works by targeting the keratin and lipids found in fungi. In the United States, the prevalence of this nail ailment ranges from 2% to 14%; it is 5.5% globally. Here, we describe a case of aplastic anaemia linked to oral terbinafine use. Clinicians should be aware of this rare adverse effect and early discontinuation of the treatment is required to prevent significant morbidity and mortality. LEARNING POINTS Aplastic anaemia is a rare side effect of terbinafine.Patients should be advised about this, and serial laboratory testing can be helpful for those who are on a long-term course of terbinafine.Early diagnosis and start of treatment can lead to a favourable outcome.
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Affiliation(s)
- Farhan Khalid
- Department of Internal Medicine, Monmouth Medical Center, New Jersey, USA
| | | | - Ahmad Al-Alwan
- Department of Internal Medicine, Monmouth Medical Center, New Jersey, USA
| | - Husam Bader
- Department of Internal Medicine, Monmouth Medical Center, New Jersey, USA
| | - Doantrang Du
- Department of Internal Medicine, Monmouth Medical Center, New Jersey, USA
| | - Trishala Meghal
- Department of Hematology/Oncology, Monmouth Medical Center, New Jersey, USA
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12
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Sengupta RK, Inamdar SA. Pregnancy With Massive Splenomegaly and Pancytopenia: A Case Report. Cureus 2023; 15:e50656. [PMID: 38229813 PMCID: PMC10790516 DOI: 10.7759/cureus.50656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/16/2023] [Indexed: 01/18/2024] Open
Abstract
Massive splenomegaly complicating pregnancy is a rare clinical entity that poses special difficulties, such as anemia, thrombocytopenia, ascites, and jaundice. This case report of a pregnant woman with large splenomegaly and pancytopenia highlights the value of prompt diagnosis and effective treatment. Splenomegaly can have a number of causes, including viral infections, hematological problems, portal hypertension, and metabolic abnormalities. A 29-year-old gravida 3 woman at 37 weeks of gestation who had massive splenomegaly was admitted and underwent a cesarean section to avoid complications of splenomegaly. The case report discusses the difficulties in obstetric management caused by enormous splenomegaly during pregnancy, including the choice of delivery method. Significant complications include splenic rupture and bleeding, particularly when pancytopenia is present. The need for several transfusions, the potential side effects of transfusion therapy, and factors related to the origin of splenomegaly when assessing maternal-fetal outcomes are discussed in this case report. The study concludes that in cases with pancytopenia splenomegaly during pregnancy, vigilant monitoring, prompt intervention, and a multidisciplinary approach are crucial to achieve positive outcomes for both the mother and the fetus.
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Affiliation(s)
- Rajasi K Sengupta
- Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Wardha, IND
| | - Saunitra A Inamdar
- Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research (Deemed to be University), Wardha, IND
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13
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Tran D, Patel K, Ashfaq A, Lyons B. Disseminated Miliary and Intestinal Tuberculosis Mimicking Inflammatory Bowel Disease. Cureus 2023; 15:e50002. [PMID: 38186434 PMCID: PMC10767475 DOI: 10.7759/cureus.50002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/09/2024] Open
Abstract
The hematogenous dissemination of Mycobacterium tuberculosis (M. tb) is commonly via the pulmonary system. Less commonly, ingestion of M. tb can lead to primary intestinal tuberculosis (TB), often misdiagnosed as inflammatory bowel disease (IBD). In extremely rare cases, the dissemination can involve cardiac infiltration/tuberculoma. One such case involves a 21-year-old man from Guatemala who spoke a rare dialect of Spanish with nonspecific complaints and an abdominal CT scan showing terminal ileum thickening suggestive of Crohn's disease (CD). A colonoscopy revealed ileitis and tissue biopsy showed granulomatous inflammation with a positive acid-fast bacillus (AFB) stain and positive blood cultures isolated for TB. Chest CT angiography (CTA) also revealed miliary nodules and a right atrial mass was confirmed with cardiac MRI. Viral serology revealed chronic hepatitis B virus (HBV) co-infection, but the patient was HIV-negative. Anti-tubercular therapy (ATT) with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE), in addition to tenofovir, was initiated, followed by a complicated hospital stay including rifampin-induced bone marrow suppression. Ultimately, he was discharged on isoniazid, pyrazinamide, ethambutol, levofloxacin, and entecavir. Intestinal TB can be misdiagnosed as IBD with the administration of steroids, potentially worsening infection. A systemic approach to clinical investigation with a thorough history using medical translators can lead to early diagnosis and treatment of intestinal and disseminated TB.
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Affiliation(s)
- Danny Tran
- Internal Medicine, Trident Medical Center, Charleston, USA
| | - Kunaal Patel
- Internal Medicine, Trident Medical Center, Charleston, USA
| | - Areeba Ashfaq
- Internal Medicine, Trident Medical Center, Charleston, USA
| | - Brittany Lyons
- Internal Medicine, Trident Medical Center, Charleston, USA
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14
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Kato H, Suzuki M, Misumi K, Kohsaka H. Macrophage activation syndrome triggered by methotrexate-related lymphoproliferative disease in a patient with rheumatoid arthritis. Immunol Med 2023; 46:191-195. [PMID: 37199221 DOI: 10.1080/25785826.2023.2212808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/06/2023] [Indexed: 05/19/2023] Open
Abstract
A 56-year-old woman was treated for rheumatoid arthritis for 17 years with methotrexate (MTX). Night sweats, fever and weight loss made her visit our hospital. Although levofloxacin failed to resolve her fever, she was suspected of having sepsis because of pancytopenia, elevated procalcitonin and a nodular lesion in the lung. After urgent hospitalization, she was diagnosed finally with the methotrexate-related lymphoproliferative disorder (MTX-LPD) associated with macrophage activation syndrome (MAS). Her general condition was improved with MTX withdrawal and 5-day high-dose glucocorticoid administration. Thus, even when the patient was critically ill with MAS, no cytotoxic agents were required to control MTX-LPD.
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Affiliation(s)
- Hirotoshi Kato
- Department of Medicine, Chiba-Nishi General Hospital, Chiba, Japan
| | - Masafumi Suzuki
- Department of Pathology, Chiba-Nishi General Hospital, Chiba, Japan
| | - Kazuo Misumi
- Department of Medicine, Chiba-Nishi General Hospital, Chiba, Japan
- Department of Cardiology, Chiba-Nishi General Hospital, Chiba, Japan
| | - Hitoshi Kohsaka
- Department of Medicine, Chiba-Nishi General Hospital, Chiba, Japan
- Rheumatology Center, Chiba-Nishi General Hospital, Chiba, Japan
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15
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Ai Q, Jiang L, Chen Y, Yao X, Yin J, Chen S. A case of KAT6A syndrome with a newly discovered mutation in the KAT6A gene, mainly manifested as bone marrow failure syndrome. Hematology 2023; 28:2182159. [PMID: 36880793 DOI: 10.1080/16078454.2023.2182159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Objective: The clinical and genetic characteristics of a child with inherited bone marrow failure syndrome as prominent clinical manifestations and special facial features were analyzed, and the etiology and mechanism were explored in, combination with clinical practice. Methods: Blood samples and clinical information were collected separately from the proband and their biological parents. The pathogenic variant was verified using next-generation sequencing technology screening, and the candidate variable sites were confirmed by using Sanger sequencing among all members of the family. Results: A heterozygous nonsense mutation in exon 17 of KAT6A (NM_006766), c.4177G > T (p.E1393*) predicted to cause truncation within the acidic domain of the protein was identified. Pedigree analysis did not reveal any variation in this locus between the proband's father and mother. No report of this pathogenic variant was found in a literature search of domestic and foreign databases, indicating that it is a newly discovered mutation. According to the guidelines of the American College of Medical Genetics, the variation was preliminarily determined to be a pathogenic. The newly discovered heterozygous mutation in KAT6A may be the cause of the disease in this child. Additionally, inherited bone marrow failure syndrome is a prominent manifestation. Conclusion: This study not only provides us with an in-depth understanding of this rare syndrome but also deepens our understanding of the function of KAT6A.
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Affiliation(s)
- Qi Ai
- Department of Hematology & Oncology, Tianjin Children's Hospital, Tianjin, People's Republic of China
| | - Lihua Jiang
- Department of Hematology & Oncology, Tianjin Children's Hospital, Tianjin, People's Republic of China
| | - Yun Chen
- Department of Hematology & Oncology, Tianjin Children's Hospital, Tianjin, People's Republic of China
| | - Xiuyun Yao
- Department of Hematology & Oncology, Tianjin Children's Hospital, Tianjin, People's Republic of China
| | - Jing Yin
- Department of Rheumatology & Immunology, Tianjin Children's Hospital, Tianjin, People's Republic of China
| | - Sen Chen
- Department of Hematology & Oncology, Tianjin Children's Hospital, Tianjin, People's Republic of China
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Ajiboye O, Vengoechea JE, Gupta R, Lomashvili K. Autosomal Recessive Adolescent Syndromic Nephronophthisis Caused by a Novel Compound Heterozygous Pathogenic Variant. Am J Case Rep 2023; 24:e941413. [PMID: 37992003 PMCID: PMC10681955 DOI: 10.12659/ajcr.941413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/17/2023] [Accepted: 09/26/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Nephronophthisis, an autosomal recessive ciliopathy involving mutations in primary cilium genes, is characterized by chronic tubulointerstitial nephritis and a defective urine concentrating capacity. It accounts for about 5% of renal failure in children and adolescents and usually progresses to end-stage renal disease before the age of 30 years. Nephronophthisis is associated with extrarenal manifestations, including retinitis pigmentosa in Senior-Loken syndrome (SLS), and liver fibrosis in 10-20% of cases. While some presenting patterns could be characteristic, patients may have atypical presentation, making diagnosis difficult. Tubulointerstitial fibrosis is the predominant feature on histology and as such, diagnosis depends mostly on genetic testing. Despite advances in renal genomics over the years with a better understanding of primary cilia and ciliary theory, about 40% of nephronophthisis cases go undiagnosed. As the underlying genetic etiologies are not fully understood, morphologic pathologic findings are non-specific, and treatment options are limited to dialysis and transplantation. CASE REPORT We describe a unique case of a patient with adolescent nephronophthisis who presented with advanced chronic kidney disease and severe pancytopenia, who progressed to end-stage renal disease at the age of 19, and was found to have syndromic nephronophthisis with compound heterozygous inheritance. CONCLUSIONS This report highlights the atypical presentation patterns that can be seen in syndromic nephronophthisis, the importance of genetic diagnosis when there is a high index of suspicion, and the need to further study genetic variants to better understand and diagnose the disease and to develop targeted therapy.
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Affiliation(s)
- Oyintayo Ajiboye
- Department of Medicine, Renal Division, Emory University School of Medicine,Atlanta, GA, USA
| | | | - Ritu Gupta
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Koba Lomashvili
- Department of Medicine, Renal Division, Emory University School of Medicine,Atlanta, GA, USA
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17
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De la Hoz I, Osman A, Ryad R, Li W, Shah S, Notman D, Isea L, Tambunan D. A Rare Presentation of Sarcoidosis in a Young Male With Acute Renal Failure: A Case Report and Literature Review. Cureus 2023; 15:e49512. [PMID: 38152816 PMCID: PMC10752653 DOI: 10.7759/cureus.49512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/29/2023] Open
Abstract
Sarcoidosis presents in a variety of ways, but historically, renal involvement has been considered rare with an incidence of 0.7% and is seldom the presenting feature of the illness. Concomitant involvement of kidney and bone marrow is extremely rare. Atypical forms of presentation, such as in this case, may pose a true diagnostic challenge. A 20-year-old African-American male presented to the emergency department with vague symptoms including fatigue, malaise, anorexia, right-sided lower back pain, and nausea. Acute kidney injury was clearly evident, creatinine was 19.78 mg/dL (normal range 0.60-1.20 mg/dL), and BUN was 124.0 mg/dL (normal range 5.0-25.0 mg/dL). Laboratory results were also remarkable for leukopenia, microcytic anemia, hyperkalemia, anion gap metabolic acidosis, and non-PTH dependent hypercalcemia. Interestingly, urinalysis was equivocal and both chest x-ray (CXR) and abdominopelvic computed tomography (CT) scan were unrevealing. The patient was admitted to the hospital and required renal replacement therapy to stabilize his clinical condition while planning for a renal biopsy that was later performed. While awaiting pathological results, pancytopenia developed, and a bone marrow biopsy was then obtained. On further investigation, angiotensin-converting enzyme (ACE) turned out to be significantly elevated suggesting sarcoidosis. Renal biopsy showed moderate acute tubular injury, tubulitis, extensive interstitial edema, and infiltration by numerous non-caseating granulomas, which confirmed the diagnosis of sarcoidosis. Bone marrow histopathology revealed hypocellularity but no granulomatous infiltration. The patient remained largely asymptomatic throughout his hospital stay, with no signs or symptoms suggesting the involvement of other organs. High-dose corticosteroids were started and continued outpatient after discharge while still on hemodialysis. Pancytopenia resolved while on glucocorticoids and improvement in renal function was such that after roughly two months of steroids, renal replacement therapy was no longer necessary. Overall, kidney injury severe enough to require hemodialysis associated with pancytopenia in a previously healthy 20-year-old constitutes a rather rare sarcoidosis presentation. This highlights the importance of considering sarcoidosis as a possible cause of kidney and bone marrow dysfunction and emphasizes the need for timely biopsy to facilitate accurate diagnosis and early initiation of appropriate therapy to avoid delayed or inadequate care, especially considering that even severe damage is potentially reversible when identified early and treated promptly.
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Affiliation(s)
| | - Alsayed Osman
- Internal Medicine, AdventHealth Orlando, Orlando, USA
| | - Robert Ryad
- Internal Medicine, AdventHealth Orlando, Orlando, USA
| | - Weiying Li
- Internal Medicine, AdventHealth Orlando, Orlando, USA
| | - Shuva Shah
- Internal Medicine, AdventHealth Orlando, Orlando, USA
| | - David Notman
- Internal Medicine, Mountain Air Health Education Center, Asheville, USA
| | - Luis Isea
- Internal Medicine, AdventHealth Orlando, Orlando, USA
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18
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Brochado AI, Marques Dias J, Azevedo Ferreira M, Grilo A, Gonçalves A. Pernicious Anemia With Spuriously Normal B12 Levels. Cureus 2023; 15:e48937. [PMID: 38106734 PMCID: PMC10725556 DOI: 10.7759/cureus.48937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/19/2023] Open
Abstract
We present a 29-year-old man admitted to our hospital with fatigue for two months of duration and recent palpitations, lightheadedness, blurred vision and nausea. Workup showed pancytopenia with severe macrocytic anemia, laboratory and blood smear features of hemolysis, low reticulocyte percentage and a negative direct Coombs test. B12 and folate levels were normal. As bone marrow aspirate was suggestive of megaloblastic anemia and upper endoscopy showed atrophic gastritis, we ordered homocysteine (elevated) and intrinsic factor (IF) antibodies (positive). The workup led to the diagnosis of pernicious anemia with spuriously normal B12 levels. Replacement therapy allowed a rapid recovery. We highlight that the presence of IF antibodies can interfere with the competitive binding assays commonly used to measure B12 levels.
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Affiliation(s)
| | | | | | - Ana Grilo
- Internal Medicine Department, Hospital Beatriz Ângelo, Loures, PRT
| | - Ana Gonçalves
- Intensive Care Unit Department, Hospital Beatriz Ângelo, Loures, PRT
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19
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Arya A, Meena SS, Matlani M, Chaudhry S, Singh V. Trends in clinical features and severity of Plasmodium vivax malaria among children at tertiary care center in North India. J Trop Pediatr 2023; 69:fmad034. [PMID: 37864522 DOI: 10.1093/tropej/fmad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
BACKGROUND Malaria is a significant cause of morbidity and mortality in adults and children. Plasmodium falciparum is the primary cause of severe malaria, but recently Plasmodium vivax is also recognized to cause severe malaria-associated morbidity and mortality. The study focuses on determining the mortality related to severity parameters in individuals under 12 years and their critical presentation in P.vivax malaria-infected children. METHODS A prospective cross-sectional hospital-based study was conducted at Safdarjung Hospital, New Delhi, and ICMR-NIMR, New Delhi. All clinically suspected cases were admitted for screening. Exclusion criteria (rapid malaria antigen test, microscopy and medication history) were applied to all the admitted patients (n = 221) to obtain P.vivax patients only. Patients aged ≤ 12 years were included in the study. DNA was extracted from dried blood spots and amplified by nested PCR, followed by visualization on gel electrophoresis. RESULT A total of 221 clinically suspected cases of malaria were screened for P.vivax. After implementing various exclusion criteria, 45/221 cases were enrolled for the study, among which 44.4% (20/45) of children had the symptoms of severe malaria in terms of cerebral malaria, thrombocytopenia, anemia, pancytopenia, acute respiratory distress syndrome and hemophagocytic lymphohistiocytosis. CONCLUSION Plasmodium vivax mono-infection can cause severe manifestation and must be treated as P.falciparum without any delay because it may lead to increased morbidity and mortality. A changing trend in clinical symptoms has shown in P.vivax which was an earlier phenomenon of P.falciparum.
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Affiliation(s)
- Aditi Arya
- Cell Biology Laboratory and Malaria Parasite Bank, ICMR-National Institute of Malaria Research, New Delhi 110077, India
| | - Shyam Sundar Meena
- Department of Pediatrics, VMMC, Safdarjung Hospital Campus, New Delhi 110029, India
| | - Monika Matlani
- Department of Microbiology, VMMC, Safdarjung Hospital Campus, New Delhi 110029, India
| | - Shewta Chaudhry
- Cell Biology Laboratory and Malaria Parasite Bank, ICMR-National Institute of Malaria Research, New Delhi 110077, India
| | - Vineeta Singh
- Cell Biology Laboratory and Malaria Parasite Bank, ICMR-National Institute of Malaria Research, New Delhi 110077, India
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20
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Kakehi M, Amano S, Sano C, Ohta R. Atypical Adult Still's Disease Complicated by Hemophagocytic Syndrome in an Older Patient: A Case Report. Cureus 2023; 15:e46922. [PMID: 38021678 PMCID: PMC10640387 DOI: 10.7759/cureus.46922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Hyperferritinemia can occur in various diseases, making the differential diagnoses diverse and often fatal. The macrophage-activated syndrome (MAS) is a differential diagnosis of hyperferritinemia in which systemic macrophages are activated and cause various symptoms. Many cases are complicated by hemophagocytic syndrome, causing pancytopenia, which can be fatal. Furthermore, it is challenging to diagnose hyperferritinemia in elderly patients, and the disease may develop into a fever of unknown origin. We report the case of a 93-year-old man with aspiration pneumonia, followed by intermittent prolonged fever complicated by abnormal hyperferritinemia and leukopenia. Based on his general condition, he was diagnosed with atypical adult Still's disease and treated with steroid pulses and tocilizumab, temporarily relieving his symptoms. However, the patient eventually developed sepsis and could not be saved. Diagnosis of hyperferritinemia in the elderly population is complex and requires immediate attention. However, invasive intervention may lead to the deterioration of an elderly patient's condition. In the context of medical care for the elderly at a community hospital, it is necessary to provide comprehensive care for those in critical condition, considering the degree of invasiveness of examinations and procedures.
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Affiliation(s)
- Minami Kakehi
- Family Medicine, Shimane University Medical School, Izumo, JPN
| | - Shiho Amano
- Community Care, Unnan City Hospital, Unnan, JPN
| | - Chiaki Sano
- Community Medicine, Shimane University Faculty of Medicine, Izumo, JPN
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21
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Ethridge BA, Dixon CJ, Vu PQ, Steadman MB, Tillman AP, Barefield NS, Ragan MC. Unusual Presentation of Coxsackievirus B and Methicillin-Sensitive Staphylococcus aureus Cellulitis Causing Sepsis. Cureus 2023; 15:e47826. [PMID: 38021765 PMCID: PMC10679847 DOI: 10.7759/cureus.47826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
The clinical association between Coxsackievirus B (CVB) and methicillin-sensitive Staphylococcus aureus (MSSA) has not been well established in the current literature. Here, we report a case of a 29-year-old male who presented with fever and malaise 24 hours after noticing a pruritic lesion on the anterior foreleg that resembled a mosquito bite. After multiple ED visits, laboratory studies, and imaging tests, the patient was admitted for treatment of high fevers and pancytopenia. The final diagnosis was viral sepsis complicated by co-infection with MSSA.
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Affiliation(s)
- Britton A Ethridge
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Cory J Dixon
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Paul Q Vu
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Michael B Steadman
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Aaron P Tillman
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Natalie S Barefield
- Department of Primary Clinical Skills, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Matthew C Ragan
- Department of Obstetrics and Gynecology, Aventa Specialized Women's Care, Dothan, USA
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22
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Jagtiani A, Veigne S, Gandhi R, Rizvi A. Haloperidol Decanoate-Induced Pancytopenia: A Case Report. Cureus 2023; 15:e47402. [PMID: 38022280 PMCID: PMC10658746 DOI: 10.7759/cureus.47402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Blood dyscrasias, including pancytopenia, can rarely occur as adverse effects of antipsychotic drug therapy. While neutropenia is more common, pancytopenia remains an infrequent but serious hematological complication. We present the case of an 85-year-old African-American female with a history of schizophrenia, stabilized on haloperidol decanoate, who developed pancytopenia during her outpatient care. Her blood counts progressively declined, leading to hospitalization. Hematology evaluation ruled out infectious or neoplastic causes, implicating haloperidol decanoate-induced pancytopenia. The pancytopenia improved gradually over three months after discontinuing haloperidol decanoate. Our case highlights the importance of monitoring and timely intervention in such cases. We discuss the rarity of pancytopenia with antipsychotics and the potential mechanisms and challenging management of this condition.
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Affiliation(s)
- Amit Jagtiani
- Psychiatry, Burrell Behavioral Health, Springfield, USA
| | | | - Raghu Gandhi
- Psychiatry, Abbott Northwestern Hospital, Minneapolis, USA
| | - Abid Rizvi
- Psychiatry and Behavioral Sciences, West Virginia University, Morgantown, USA
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23
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Moore CE, Marshall L. Diagnosing Extrapulmonary Sarcoidosis and the Implications of Diagnosis on Military Service. Cureus 2023; 15:e47115. [PMID: 38021643 PMCID: PMC10647944 DOI: 10.7759/cureus.47115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Sarcoidosis is a systemic inflammatory disease that can cause granulomatous infiltration of almost all organs and tissues which allows for a wide variety of presentations that may overlap with other disease processes. Renal sarcoidosis is a much rarer site of extrapulmonary involvement and may present as hypercalcemia, tubular or glomerular dysfunction, and/or granulomatous interstitial nephritis. Prompt diagnosis of sarcoidosis is crucial for initiating appropriate treatment and avoiding organ dysfunction. Herein, we describe a case of an armed forces service member who developed extrapulmonary sarcoidosis and renal sarcoidosis with acute complications refractory to glucocorticoids requiring adalimumab. The case highlights and emphasizes a rare manifestation of extrapulmonary sarcoidosis, the importance of avoiding premature closure of the differential diagnosis to avoid diagnostic delay and treatment imitation, and the unique clinical reasoning that occurs in active-duty personnel where diagnoses and subsequent treatments can have career implications and affect the ability of the service member to maintain the ability to deploy worldwide.
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Affiliation(s)
- Caroline E Moore
- Internal Medicine, Naval Medical Center San Diego, San Diego, USA
| | - Landry Marshall
- Internal Medicine, Naval Medical Center Camp Lejeune, Camp Lejeune, USA
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24
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Meena M, Khichar S, Pawar A, Midha N, Kumar S, Purohit A, Bohra GK, Garg MK, Singhai A. Iron Deficiency Anemia Presenting With Pancytopenia: A Study From India. Cureus 2023; 15:e45034. [PMID: 37829950 PMCID: PMC10566395 DOI: 10.7759/cureus.45034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
INTRODUCTION Iron deficiency anemia (IDA) is the most common cause of anemia worldwide. IDA is commonly associated with thrombocytosis and normal or slightly decreased leukocyte count. Sometimes it can present with thrombocytopenia, but rarely present with pancytopenia. Here we are presenting six cases of severe iron deficiency presenting with pancytopenia, which responded to iron replenishment. METHODS This 12-month observational study was conducted in the Department of General Medicine at a tertiary care Centre in India. All cases of pancytopenia (after exclusion of other causes) with IDA were included. IDA was established with the help of a complete blood count (CBC), peripheral smear examination, serum iron studies, and serum ferritin. Results: In our study, CBC at four weeks later of iron transfusion without other supplementation showed significant improvement in hematological parameters. CONCLUSION Severe iron deficiency is a reversible etiology of pancytopenia. It should be kept as a differential diagnosis of pancytopenia if common causes of pancytopenia are ruled out.
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Affiliation(s)
- Mahadev Meena
- General Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Satyendra Khichar
- General Medicine, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Akash Pawar
- General Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Naresh Midha
- General Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Saurabh Kumar
- Neurology, King George's Medical University (KGMU), Lucknow, IND
| | - Abhishek Purohit
- Pathology and Hematopathology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Gopal K Bohra
- General Medicine, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Mahendra Kumar Garg
- General Medicine, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Abhishek Singhai
- General Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
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25
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Alobaidi A, Albadry A, Murray A. Very Severe Aplastic Anemia in a 26-Year-Old Male: Implications for Prognosis and Treatment Options. Cureus 2023; 15:e45750. [PMID: 37872935 PMCID: PMC10590479 DOI: 10.7759/cureus.45750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/25/2023] Open
Abstract
Aplastic anemia (AA) is a hematopoietic stem cell (HSC) disorder characterized by the loss of HSCs, bone marrow failure, and peripheral pancytopenia. AA is classified as very severe (VSAA), severe (SAA), or non-severe (NSAA) based on the severity criteria. This classification system has implications for the prognosis and treatment options offered to patients. The prognosis of AA has improved over the past several decades with the advancements in supportive care, HSC transplant (HCT), and immunosuppressive therapy (IST). In this report, we present the case of a 26-year-old male diagnosed with VSAA after presenting with severe neutropenia and fever. The patient ultimately underwent HSC transplantation.
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Affiliation(s)
| | - Ahmed Albadry
- Faculty of Medicine, Charles University in Prague, Prague, CZE
| | - Anne Murray
- Clinical Research Institute, Methodist Health System, Dallas, USA
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26
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Wang T, Rampisela D. Visceral Leishmaniasis With Blastocystis Co-infection: A Case Report. Cureus 2023; 15:e44050. [PMID: 37746419 PMCID: PMC10517707 DOI: 10.7759/cureus.44050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Visceral leishmaniasis (VL) is a form of leishmaniasis, which causes significant mortality if untreated. The coexistence of VL with Blastocystis infection has not been well-documented in the literature. In this paper, we present the case of a 72-year-old male who experienced four months of recurrent diarrhea and later developed weight loss, fever, night sweats, and pancytopenia. The stool ova and parasite (O&P) examination revealed Blastocystis spp. vacuolar bodies and he was treated with metronidazole which resolved the diarrhea but not other symptoms. Further evaluation, including an abdominal Computed Tomogram (CT) scan and ultrasonography (USG), revealed splenomegaly. A splenic biopsy confirmed VL with numerous Leishmania amastigotes. Treatment with Amphotericin B led to clinical improvement. This paper discusses the clinical and diagnostic features of VL and Blastocystis, highlighting their differential diagnosis, and available treatments.
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Affiliation(s)
- Tengfei Wang
- Pathology, Baylor Scott & White Health, Temple, USA
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27
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Shahab S, Semerdzhiev DI, Reeves J, Daniel A, Martin DE, Sukpraprut-Braaten S. Waldenstrom Macroglobulinemia: Clinical Presentation, Diagnosis, and Management in an Elderly Male. Cureus 2023; 15:e44127. [PMID: 37750145 PMCID: PMC10518236 DOI: 10.7759/cureus.44127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/27/2023] Open
Abstract
Waldenstrom macroglobulinemia (WM) is a rare lymphoproliferative disease that can have an ambiguous clinical presentation. A key component of the pathophysiology of WM is bone marrow infiltration, which most commonly presents as anemia. Other symptoms of WM tend to be generalized and non-specific, which presents a diagnostic challenge. This was the case with our patient as well, when he presented to our outpatient clinic with non-specific symptoms. We present a 79-year-old male with longstanding pancytopenia, polyarthralgia, bilateral pedal edema, decreased appetite, and increased bleeding from wounds. The patient had a complete blood count (CBC) and complete metabolic panel (CMP) done, confirming present anemia, which prompted inpatient treatment and an oncology workup, confirming WM. The patient began a zanubrutinib monotherapy regimen, showing improvement in his pancytopenia, polyarthralgia, and overall symptoms.
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Affiliation(s)
- Shahman Shahab
- Medicine, Arkansas College of Osteopathic Medicine, Fort Smith, USA
| | - Dimitar I Semerdzhiev
- Medicine, Unity Health, Searcy, USA
- Medicine, Arkansas College of Osteopathic Medicine, Fort Smith, USA
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Patel A, Chabot F, Hamid O. From Weakness to Wellness: A Rare Case of Severe Pancytopenia and Vitamin B12 Deficiency. Cureus 2023; 15:e44017. [PMID: 37746468 PMCID: PMC10517378 DOI: 10.7759/cureus.44017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/26/2023] Open
Abstract
Vitamin B12 (cobalamin) deficiency is a commonly seen nutritional deficiency that presents with a broad spectrum of clinical symptoms. In this report, we describe a case of a 49-year-old female patient who presented to the emergency department with sudden onset of a syncopal-like episode, generalized weakness, and severe pancytopenia, who was subsequently diagnosed with vitamin B12 deficiency upon admission. The patient underwent a thorough evaluation to exclude alternative etiologies for her presentation. Her clinical symptoms and blood count significantly improved after six days of treatment with vitamin B12 supplementation. While vitamin B12 deficiency is a commonly recognized issue, healthcare providers should be aware of its infrequent presentations. Our case serves as a reminder to clinicians to remain vigilant for acute onset manifestations and consider vitamin B12 deficiency as a differential diagnosis for the early management of pancytopenia.
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Affiliation(s)
- Aagna Patel
- Department of Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
| | - Francis Chabot
- Department of Family Medicine, Mohawk Valley Health System, Utica, USA
| | - Osman Hamid
- Department of Family Medicine, Mohawk Valley Health System, Utica, USA
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29
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Gu HY, Zhao JW, Wang YS, Meng ZN, Zhu XM, Wang FW, Zheng AH, Wu GQ. Case Report: Life-threatening pancytopenia with tislelizumab followed by cerebral infarction in a patient with lung adenocarcinoma. Front Immunol 2023; 14:1148425. [PMID: 37559729 PMCID: PMC10409480 DOI: 10.3389/fimmu.2023.1148425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 07/10/2023] [Indexed: 08/11/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are an integral antitumor therapy for many malignancies. Most patients show very good tolerability to ICIs; however, serious immune-related adverse events (irAEs) with ICIs have been well documented and prevent some patients from continuing ICIs or even become the direct cause of patient death. Cytopenia is a rare irAE but can be life-threatening. Here, we present the case of a 66-year-old male patient with metastatic lung adenocarcinoma who received two doses of chemotherapy + PD-1 antibody tislelizumab and developed pancytopenia after each dose. Although the first episode of pancytopenia resolved with a treatment regimen of granulocyte colony-stimulating factor (G-CSF), thrombopoietin (TPO), and red blood cell and platelet transfusion, the second episode showed extreme resistance to these treatments and improved only after the administration of steroids. His second pancytopenia episode resolved after a long course of treatment with methylprednisolone, G-CSF, TPO, hetrombopag and multiple red blood cell and platelet transfusions. However, he suffered a cerebral infarction when his platelet count was in the normal range and gradually recovered 1 week later. This case highlights the importance of the early recognition and management of hematological irAEs.
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Affiliation(s)
- Hang-Yu Gu
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jing-Wen Zhao
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yin-Shuang Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhuo-Nan Meng
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xiu-Ming Zhu
- Cancer Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Fu-Wei Wang
- Cancer Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Ai-Hong Zheng
- Cancer Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Guo-Qing Wu
- Cancer Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
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30
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Massimino M, Iaquinta FS, Naty S, Andreozzi F, Grembiale RD. Persistent Pancytopenia as a Long-COVID Manifestation in a Patient with Adult-Onset Still's Disease: A Case Report. Medicina (Kaunas) 2023; 59:1349. [PMID: 37512160 PMCID: PMC10384992 DOI: 10.3390/medicina59071349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023]
Abstract
Background: Adult-onset Still's disease (AOSD) is a rare rheumatic inflammatory condition with an extremely heterogeneous clinical presentation and systemic impairment. Uncommon manifestations may be challenging to manage, especially in patients with previous severe acute SARS-CoV-2 infection. For the first time, we report the case of a patient affected by refractory AOSD presenting with severe pancytopenia as a long-COVID manifestation. The purpose of this case report is to illustrate the clinical presentation, diagnostic and therapeutic management of this unusual manifestation. Moreover, we examine the mechanisms that are potentially responsible for the onset of the pancytopenia observed in our patient. Case presentation: We describe the case of a 40-year-old male who presented with a history of fever for 2 years, arthralgia, maculopapular salmon-pink rash and a previous SARS-CoV-2 infection which required admission to intensive care. The patient's laboratory results revealed elevated inflammatory markers levels (erythrocyte sedimentation rate and C-reactive protein), hyperferritinemia and severe pancytopenia that needed multiple transfusions. A diagnosis of AOSD was made based on clinical and laboratory presentation after excluding neoplastic, infectious and other rheumatic diseases. The previous empirical treatment was not adequate to control the condition; therefore, treatment with high-dose steroids, canakinumab and epoetin alfa was started and led to the resolution of the man's symptoms and a reduction in inflammatory marker levels, whereas blood cell count remained stable without a need for further blood transfusions. The patient is currently under rheumatologic and hematologic follow-up every month. Conclusions: Neither AOSD nor SARS-CoV-2 infection usually manifests with pancytopenia, except in hemophagocytic syndrome or immunodeficient patients, respectively. Identifying the underlying etiology of pancytopenia is mandatory to establish a prompt treatment that generally resolves the disorder. However, in our case, all common causes of pancytopenia were excluded, suggesting a potential manifestation of the long-COVID syndrome. Despite the resolution of the acute infection and the remarkable treatment of AOSD, pancytopenia persists. Herein, we propose for refractory AOSD patients with previous SARS-CoV-2 infection a novel approach to the diagnosis and treatment of pancytopenia.
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Affiliation(s)
- Mattia Massimino
- Department of Medical and Surgical Sciences, "Magna Græcia" University of Catanzaro, 88100 Catanzaro, Italy
| | | | - Saverio Naty
- Department of Health Sciences, "Magna Græcia" University of Catanzaro, 88100 Catanzaro, Italy
| | - Francesco Andreozzi
- Department of Medical and Surgical Sciences, "Magna Græcia" University of Catanzaro, 88100 Catanzaro, Italy
| | - Rosa Daniela Grembiale
- Department of Health Sciences, "Magna Græcia" University of Catanzaro, 88100 Catanzaro, Italy
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31
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Litwin T, Antos A, Bembenek J, Przybyłkowski A, Kurkowska-Jastrzębska I, Skowrońska M, Członkowska A. Copper Deficiency as Wilson's Disease Overtreatment: A Systematic Review. Diagnostics (Basel) 2023; 13:2424. [PMID: 37510170 PMCID: PMC10377829 DOI: 10.3390/diagnostics13142424] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/11/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Treatment of Wilson's disease (WD), an inherited disease characterized by copper overload, is lifelong and there is the possibility that copper deficiency (CD) may occur. We systematically reviewed the literature to describe treatment patterns, symptoms and outcomes associated with CD. METHODS Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, the PubMed database was searched up to 6 April 2023. RESULTS Across 17 articles, 20 cases of CD were described, most commonly (15 cases) in WD patients treated with zinc salts (ZS), less often on combined chelator and ZS therapy (3 cases), molybdate salts plus ZS (1), or molybdate alone (1). CD symptoms occurred insidiously, including sideroblastic anemia, neutropenia, axonal sensory neuropathy, posterior cord myelopathy and increased ratio of epileptic seizures (or epilepsy). CD diagnosis was based on symptoms and severely reduced urinary copper excretion (<20 µg/24 h [<0.3 µmol/24 h] on ZS, or <100 µg/24 h [<1.6 µmol/24 h] on chelators) with low total serum copper and ceruloplasmin. CONCLUSIONS Awareness of CD and regular monitoring of copper metabolism is needed during WD treatment. Temporary cessation of anti-copper treatment usually reverses serum copper reductions as well as pancytopenia; however, some symptoms, especially neuropathy and myelopathy, may persist.
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Affiliation(s)
- Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland
| | - Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland
| | - Jan Bembenek
- Department of Clinical Neurophysiology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland
| | - Adam Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | | | - Marta Skowrońska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland
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Elosiuba E, Layton O, Salem A. First Presentation and Diagnosis of a Rare Advanced Gynaecological Cancer in Emergency Department: A Case Report. J West Afr Coll Surg 2023; 13:116-118. [PMID: 37538213 PMCID: PMC10395844 DOI: 10.4103/jwas.jwas_27_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/22/2023] [Indexed: 08/05/2023]
Abstract
A case of rare endometrial carcinosarcoma with locoregional spread and sigmoid fistula presenting for the very first time at a hospital emergency department (ED). A 56-year-old female presented with abdominal pain, diarrhea, fever, and pancytopenia, which was diagnosed as advanced gynaecological cancer following assessment, imaging, and tissue biopsy. Increased pressure on the ED owing to coronavirus disease 2019 pandemic may cause the first presentation of gynae-oncology cases to ED physician. A full return of all primary care services may reduce such pressure, improve early detection of gynaecological malignancies, allow early multidisciplinary team care, and result in better patient experience in the long run.
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Affiliation(s)
- Emeka Elosiuba
- Emergency Department, Stoke Mandeville Hospital, Aylesbury, UK
| | - Olivia Layton
- Emergency Department, Stoke Mandeville Hospital, Aylesbury, UK
| | - Ammar Salem
- Emergency Department, Stoke Mandeville Hospital, Aylesbury, UK
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33
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Pipitò L, Medaglia A, Russotto I, Bonura S, Cascio A. Multisystem Inflammatory Syndrome: A Case in an Adult With Controlled Lymphoma and a Persistent SARS-CoV-2 Infection. Cureus 2023; 15:e40776. [PMID: 37485170 PMCID: PMC10362473 DOI: 10.7759/cureus.40776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
Multisystem inflammatory syndrome (MIS) is a new and rare complication of COVID-19 that usually occurs in children. An increasing number of cases of MIS in adults are described in the literature. The condition is associated with high mortality, and treatment is non-standardized. Clinical pictures are heterogeneous, and diagnosis is very challenging. Here we describe a case of MIS in a 60-year-old man with previous follicular lymphoma treated with obinutuzumab and recent SARS-CoV-2 infections. He complained of an unknown fever and developed pancytopenia during the hospitalization, associated with a general clinical worsening. The patient was successfully treated with intravenous immunoglobulin and steroids.
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Affiliation(s)
- Luca Pipitò
- Department of Infectious and Tropical Diseases, Azienda Ospedaliera Universitaria Policlinico (AOUP) Paolo Giaccone, Palermo, ITA
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, ITA
| | - Alice Medaglia
- Department of Infectious and Tropical Diseases, Azienda Ospedaliera Universitaria Policlinico (AOUP) Paolo Giaccone, Palermo, ITA
| | - Irene Russotto
- Department of Infectious and Tropical Diseases, Azienda Ospedaliera Universitaria Policlinico (AOUP) Paolo Giaccone, Palermo, ITA
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, ITA
| | - Silvia Bonura
- Department of Infectious and Tropical Diseases, Azienda Ospedaliera Universitaria Policlinico (AOUP) Paolo Giaccone, Palermo, ITA
| | - Antonio Cascio
- Department of Infectious and Tropical Diseases, Azienda Ospedaliera Universitaria Policlinico (AOUP) Paolo Giaccone, Palermo, ITA
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, ITA
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34
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Pimentel Campillo J, Corona Castillo D, Nunez M, Finke Abbott A, Pichardo J. Pneumonia-Induced Thyroid Crisis With Thyrotoxicosis Exacerbation: De Novo Graves' Disease Presentation on a Cornelia de Lange Syndrome (CdLS). Cureus 2023; 15:e41119. [PMID: 37519569 PMCID: PMC10382790 DOI: 10.7759/cureus.41119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Cornelia de Lange syndrome (CdLS) is a rare genetic disorder that affects multiple organ systems and is characterized by distinctive facial features, growth retardation, and developmental disabilities. The syndrome is caused by mutations in genes (NIPBL, RAD21, SMC3, HDAC8, and SMC1A) involved in the cohesin complex, which plays a critical role in chromosome segregation and gene expression regulation. Clinical findings typically include dysmorphic facial features (arched eyebrows, synophrys, long eyelashes, ptosis, long philtrum, thin upper lip, and posteriorly rotated ears), growth and mental retardation, upper limb defects (clinodactyly and limb deficiencies), gastrointestinal complications (gastroesophageal reflux, pyloric stenosis, diaphragmatic hernia, malrotation, and volvulus), and heart defects (ventricular and atrial septal defects). In addition, chronic respiratory tract infections including sinusitis and pneumonia have been frequently described in this population. The early recognition and diagnosis of CdLS through genetic testing are crucial to ensure appropriate medical management and early intervention therapies to improve the outcomes of affected individuals. The thyroid gland is not affected by this congenital disease, but complications can arrive in this organ by other disease-related organ malfunctions. Pneumonia-induced thyroiditis is a potentially life-threatening condition that can occur in patients with underlying thyroid disease who also develop pneumonia. The symptoms are due to the hypermetabolic state induced by excess thyroid hormones and include weight loss, heat intolerance, and palpitations. There are many different causes of thyrotoxicosis. It is important to determine the cause since treatment is based on the underlying etiology. The diagnosis of pneumonia-induced thyrotoxicosis can be challenging as symptoms may mimic other conditions and laboratory testing may not always provide a clear answer. The diagnosis is confirmed with low thyroid-stimulating hormone (TSH) and elevated free thyroxine (T4) and triiodothyronine (T3), erythrocyte sedimentation rate (ESR), and C-reactive protein. The management of the condition involves prompt recognition, supportive care, and the use of medications to lower thyroid hormone levels, such as beta-blockers, antithyroid drugs, steroids, and iodine. In severe cases, plasmapheresis or thyroidectomy may be necessary.
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Affiliation(s)
- Jorge Pimentel Campillo
- Internal Medicine, Centros de Diagnóstico y Medicina Avanzada y de Conferencias Médicas y Telemedicina (CEDIMAT), Santo Domingo, DOM
| | - Daneybi Corona Castillo
- Endocrinology, Diabetes, and Metabolism, Centros de Diagnóstico y Medicina Avanzada y de Conferencias Médicas y Telemedicina (CEDIMAT), Santo Domingo, DOM
| | - Marco Nunez
- Pediatrics, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Jesús Pichardo
- Surgery and Specialties, Centros de Diagnóstico y Medicina Avanzada y de Conferencias Médicas y Telemedicina (CEDIMAT), Santo Domingo, DOM
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35
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Ghazal F, Zur M, Silver A. Combined Presentation of Acute Confusion and Severe Pancytopenia in Vitamin B12 Deficiency. Cureus 2023; 15:e40236. [PMID: 37435265 PMCID: PMC10332886 DOI: 10.7759/cureus.40236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 07/13/2023] Open
Abstract
Vitamin B12 deficiency is more prevalent in the elderly and can develop as a result of malnutrition, malabsorption, chronic alcoholism, and chronic use of common medications (e.g. metformin, PPI, methotrexate) along with other causes. A wide spectrum of hematological and neuropsychiatric manifestations exist with the most common being Megaloblastic anemia and subacute combined degeneration, respectively. The mechanisms leading to the manifestations specific to these two organ systems are thought to be different. The severity of neuropsychiatric presentation is reported to be inversely proportional to that of hematological presentation, thus making it uncommon for both to be readily apparent simultaneously. Regardless of the severity of the clinical presentation, a good response to vitamin B12 replacement therapy is reported despite the lack of guidelines regarding dosing, frequency, or duration of treatment needed to note improvement in manifestations. The aim of this report is to increase the provider's knowledge that a severe combined hematological and neuropsychiatry manifestation can co-exist and report the management used for recovery.
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Affiliation(s)
- Fatima Ghazal
- Internal Medicine, University of Connecticut School of Medicine, Farmington, USA
| | - Michelle Zur
- Internal Medicine, University of Connecticut Health, Farmington, USA
| | - Aaron Silver
- Hospital Medicine, Hartford Hospital, Hartford, USA
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36
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Bhatti H, Batbileg E, De S, Friedman G, Antony S. Acute Colonic Perforation with Septic Shock Secondary to Disseminated Histoplasmosis in an Autologous Bone Marrow Transplant Recipient. Infect Drug Resist 2023; 16:3029-3034. [PMID: 37215300 PMCID: PMC10199683 DOI: 10.2147/idr.s402228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
Histoplasma capsulatum is an opportunistic pathogen which can lead to a wide variety of clinical presentations in the immunocompromised host. Post-transplant histoplasmosis in hematopoietic cell transplant recipients is exceedingly rare, with an incidence of <1%. We present a case of acute caecal perforation resulting from disseminated histoplasmosis in a patient who had undergone autologous bone marrow transplant for plasma cell dyscrasia. This is a 71-year-old patient who initially presented due to progressive weakness associated with shortness of breath.
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Affiliation(s)
- Harsimrandeep Bhatti
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
| | - Enkhbileg Batbileg
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
| | - Srijisnu De
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
| | - Glen Friedman
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
| | - Suresh Antony
- Department of Internal Medicine, Las Palmas Del Sol Medical Center, El Paso, TX, USA
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37
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Reddy T, Kotha R, M A. An Unusual Presentation of Extremely Early Neonatal Cirrhosis in Shwachman-Diamond Syndrome: A Case Report. Cureus 2023; 15:e38583. [PMID: 37288222 PMCID: PMC10241746 DOI: 10.7759/cureus.38583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 06/09/2023] Open
Abstract
Exocrine pancreatic insufficiency, haematological dysfunction, and skeletal abnormalities are the three clinical characteristics of the rare inherited bone marrow failure syndrome (IBMFS), known as Shwachman-Diamond syndrome (SDS). Cirrhosis at a neonatal age is uncommon and is typically not documented, as in neonatal presentation. Here, we present a case of SDS in which bi-cytopenia with macro-nodular cirrhosis emerged before the age of one month. Utilising genetic testing on the infant and both parents, we were able to confirm the diagnosis. We were expecting a higher-level liver transplant set-up, but the infant passed away in the interim. Genetic studies play a significant part in the diagnosis of difficult cases.
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Affiliation(s)
- Tejaswy Reddy
- Department of Neonatology, Niloufer Hospital, Hyderabad, IND
| | - Rakesh Kotha
- Department of Neonatology, Osmania Medical College, Hyderabad, IND
| | - Alimelu M
- Department of Neonatology, Niloufer Hospital, Hyderabad, IND
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38
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Vamshikrishnapatel K, Biswas R, Ojha VS, Hegde AV, Kumar V. Hemophagocytic Lymphohistiocytosis With Obstructive Jaundice as a Rare Presentation of Disseminated Tuberculosis in an Adult. Cureus 2023; 15:e38875. [PMID: 37313089 PMCID: PMC10259685 DOI: 10.7759/cureus.38875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/15/2023] Open
Abstract
Tuberculosis (TB) is a disease of global concern due to its varying clinical presentations and outcomes. Hemophagocytic lymphohistiocytosis (HLH) syndrome, along with obstructive jaundice, is one of the rarest presentations of tuberculosis involving immune activation and has a very high mortality rate. Thus, on-time diagnosis becomes crucial for the management of the disease. Prompt treatment with anti-tubercular therapy (ATT) can limit the morbidity and mortality associated with it. We report the case of a 28-year-old male who presented with fever, yellowish discoloration of the skin, features of bicytopenia, jaundice with hepatosplenomegaly, and ascites. The liver function test (LFT) was suggestive of obstructive jaundice. TB was confirmed on the analysis of lymph node aspirates, and the contrast-enhanced computed tomography (CECT) of the thorax and abdomen was suggestive of disseminated tuberculosis. Upon investigation, the criteria for HLH were fulfilled. Bone marrow aspiration smears revealed multiple hemophagocytic histiocytes in the background of a hypercellular marrow, erythroid hyperplasia, and myeloid-to-erythroid ratio of 1:1. Thus, a diagnosis of disseminated TB with HLH and obstructive jaundice was established. A modified ATT regimen was started, keeping in mind the deranged LFT of the patient, but no immunosuppressive therapy was initiated as it could make the TB worse. This case demonstrates the fact that in cases of hemophagocytic syndrome with tuberculosis as an underlying cause, just starting ATT without immunosuppression could be rewarding and lifesaving.
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Affiliation(s)
| | - Ratnadeep Biswas
- Internal Medicine, All India Institute of Medical Sciences, Patna, IND
| | - Vishnu S Ojha
- Internal Medicine, All India Institute of Medical Sciences, Patna, IND
| | - Aniketh V Hegde
- Internal Medicine, All India Institute of Medical Sciences, Patna, IND
| | - Vijay Kumar
- Internal Medicine, All India Institute of Medical Sciences, Patna, IND
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39
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Thakur B, Hiwale KM. Fanconi Anemia: A Rare Genetic Disorder. Cureus 2023; 15:e38899. [PMID: 37303314 PMCID: PMC10257508 DOI: 10.7759/cureus.38899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Fanconi anemia is a rare genetic disorder affecting various body systems. Congenital abnormalities, poor hematopoiesis, a higher incidence of acute myeloid leukemia, myelodysplastic syndrome, and malignancies are the hallmarks of this autosomal recessive condition. In certain instances, the clinical signs and highly diverse phenotypic presentation make a diagnosis challenging. In this case report, an eight-year-old boy presented with recurrent episodes of fever, generalized weakness and physical deformities. He had left thumb deformity, triangular face, short stature, and hyperpigmentation with café au lait spots. Bone marrow biopsy revealed hypoplastic marrow, peripheral blood smear revealed pancytopenia, and chromosomal breakage testing was also positive.
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Affiliation(s)
- Bharati Thakur
- Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - K M Hiwale
- Pathology, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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40
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Tessier S, Aiad M, Longo S, Wilson M, Faroun Y. Refractory pancytopenia upon initiation of asciminib in tyrosine kinase inhibitor-resistant chronic myeloid leukemia. Int J Crit Illn Inj Sci 2023; 13:78-81. [PMID: 37547190 PMCID: PMC10401557 DOI: 10.4103/ijciis.ijciis_85_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 12/31/2022] [Accepted: 01/13/2023] [Indexed: 08/08/2023] Open
Abstract
Asciminib, a "Specifically Targeting the ABL Myristoyl Pocket" inhibitor, is a new drug in the treatment of tyrosine kinase inhibitor (TKI)-resistant chronic myeloid leukemia (CML). Hemocytopenias associated with asciminib are common adverse events documented by clinical trials. We report a case of precipitous-onset pancytopenia with the initiation of asciminib treatment in a patient with TKI-resistant CML. This case had a confounding array of laboratory findings that evidenced a drug-induced hemophagocytic component. We hope that our case stimulates further reporting of similar cases to enhance the understanding of the pathophysiology underlying asciminib-induced hemocytopenias.
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Affiliation(s)
- Steven Tessier
- Department of Medicine, St. Luke’s University Health Network, Bethlehem, Pennsylvania, USA
| | - Mina Aiad
- Department of Medicine, St. Luke’s University Health Network, Bethlehem, Pennsylvania, USA
| | - Santo Longo
- Department of Pathology, St. Luke’s University Health Network, Bethlehem, Pennsylvania, USA
| | - Melissa Wilson
- Department of Hematology and Oncology, St. Luke’s University Health Network, Bethlehem, Pennsylvania, USA
| | - Yacoub Faroun
- Department of Hematology and Oncology, St. Luke’s University Health Network, Bethlehem, Pennsylvania, USA
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Yeung C, Relke N, Good D, Satkunam N, Mates M. Antithymocyte globulin for aplastic anemia secondary to pembrolizumab: a case report and review of literature. Immunotherapy 2023; 15:323-333. [PMID: 36852421 DOI: 10.2217/imt-2022-0210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Aplastic anemia is a rare but potentially serious complication of immune checkpoint inhibitor therapy. The authors present a case of pembrolizumab-induced aplastic anemia that was refractory to steroids but had some hematologic response to modified-dosing antithymocyte globulin (ATG). This is the first reported case of hematological response to ATG for immune checkpoint inhibitor-induced aplastic anemia and the first reported case of modified ATG dosing for this indication. Cases of immune checkpoint inhibitor-induced aplastic anemia and management options are also summarized. Given the high morbidity and mortality associated with ICI-induced aplastic anemia, more data is necessary to guide evidence-based management recommendations.
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Affiliation(s)
- Cynthia Yeung
- Department of Medicine, Queen's University & Kingston Health Sciences Centre, Kingston, K7L 2V7, Canada
| | - Nicole Relke
- Department of Medicine, Queen's University & Kingston Health Sciences Centre, Kingston, K7L 2V7, Canada
| | - David Good
- Department of Pathology & Molecular Medicine, Queen's University & Kingston Health Sciences Centre, Kingston, K7L 2V7, Canada
| | - Natasha Satkunam
- Department of Medicine, Queen's University & Kingston Health Sciences Centre, Kingston, K7L 2V7, Canada
| | - Mihaela Mates
- Department of Oncology, Queen's University & Kingston Health Sciences Centre, Kingston, K7L 2V7, Canada
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Gallo Marin B, Ollila TA, Robbins A, Brooks BE, Firoz EF, Massoud CM. Drug-induced hypersensitivity syndrome and eosinophils in skin biopsy in a patient with pancytopenia. Am J Hematol 2023; 98:697-699. [PMID: 36151897 PMCID: PMC10033331 DOI: 10.1002/ajh.26742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Benjamin Gallo Marin
- Division of Hematology and Oncology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
- Brown Dermatology and Pathology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Thomas A. Ollila
- Division of Hematology and Oncology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Allison Robbins
- Brown Dermatology and Pathology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Blake Elizabeth Brooks
- Brown Dermatology and Pathology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Elnaz F. Firoz
- Brown Dermatology and Pathology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Cathy M. Massoud
- Brown Dermatology and Pathology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
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Fonseca J, Silveira J, Faísca P, de Almeida PM. Presumptive hemophagocytic syndrome associated with co-infections with FIV, Toxoplasma gondii, and Candidatus mycoplasma haemominutum in an adult cat. Vet Clin Pathol 2023. [PMID: 36975170 DOI: 10.1111/vcp.13205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/20/2022] [Accepted: 10/11/2022] [Indexed: 03/29/2023]
Abstract
A 9-year-old neutered male cat, previously test-positive for feline immunodeficiency virus (FIV), was presented with an history of vomiting, hyporexia, and weight loss. Panleukopenia was identified on complete blood counts, and bone marrow evaluation revealed ineffective granulocytic hyperplasia and rare neutro-, erythro-, and rubriphagocytosis. Prednisolone was initiated with no response, and progression to pancytopenia occurred. On abdominal ultrasonographic examination, splenomegaly was present. PCR testing was positive for Candidatus Mycoplasma haemominutum and IgG antibodies against Toxoplasma gondii were detected (titer 1:2560). Treatment with antibiotics, feline recombinant interferon-ω, chlorambucil, mycophenolate, and raltegravir was implemented with no clinical improvement, and splenectomy was performed. Cytologic evaluation of splenic aspirates revealed exuberant neutro-, erythro-, and rubriphagocytosis. Histopathology of the spleen also showed many erythrophagocytic macrophages with no evidence of malignancy, and a diagnosis of hemophagocytic syndrome (HS) was made. The WBC count and hematocrit reached reference values 1 day and 3 months, respectively, after splenectomy. The cat was treated with cyclosporine and lomustine. Disease progression led to the development of septic hepatitis, and the cat was euthanized. To our knowledge, this is the first case of presumptive HS in cats that might have been associated with FIV, Toxoplasma gondii, and Candidatus Mycoplasma haemominutum co-infection.
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Affiliation(s)
- Joana Fonseca
- Faculty of Veterinary Medicine, Lusófona University, Lisbon, Portugal
| | - João Silveira
- Faculty of Veterinary Medicine, Lusófona University, Lisbon, Portugal
| | - Pedro Faísca
- Faculty of Veterinary Medicine, Lusófona University, Lisbon, Portugal
- Faculty of Veterinary Medicine, CBIOS, Research Center for Biosciences and Health Technologies, Lusófona University, Lisbon, Portugal
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Costanzo G, Sambugaro G, Mandis G, Vassallo S, Scuteri A. Pancytopenia Secondary to Vitamin B12 Deficiency in Older Subjects. J Clin Med 2023; 12:jcm12052059. [PMID: 36902847 PMCID: PMC10003837 DOI: 10.3390/jcm12052059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Vitamin B12 (cobalamin CBL) is a water-soluble vitamin required to form hematopoietic cells (red blood cells, white blood cells, and platelets). It is involved in the process of synthesizing DNA and myelin sheath. Deficiencies of vitamin B12 and/or folate can cause megaloblastic anemia (macrocytic anemia with other features due to impaired cell division). Pancytopenia is a less frequent exordium of severe vitamin B12 deficiency. Vitamin B12 deficiency can also cause neuropsychiatric findings. In addition to correcting the deficiency, an essential aspect of management is determining the underlying cause because the need for additional testing, the duration of therapy, and the route of administration may differ depending on the underlying cause. METHODS Here, we present a series of four patients hospitalized for megaloblastic anemia (MA) in pancytopenia. All patients diagnosed with MA were studied for a clinic-hematological and etiological profile. RESULTS All the patients presented with pancytopenia and megaloblastic anemia. Vitamin B12 deficiency was documented in 100% of cases. There was no correlation between the severity of anemia and deficiency of the vitamin. Overt clinical neuropathy was present in none of the cases of MA, while subclinical neuropathy was seen in one case. The etiology of vitamin B12 deficiency was pernicious anemia in two cases and low food intake in the remaining cases. CONCLUSION This case study emphasizes the role of vitamin B12 deficiency as a leading cause of pancytopenia among adults.
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Affiliation(s)
- Giulia Costanzo
- S.C. di Medicina Interna, Policlinico Universitario Monserrato “Duilio Casula”—AOU di Cagliari, 09123 Cagliari, Italy
| | - Giada Sambugaro
- Scuola Specializzazione Allergologia e Immunologia Clinica, Universita’ di Cagliari, 09124 Cagliari, Italy
| | - Giulia Mandis
- Scuola Specializzazione Medicina Interna, Universita’ di Cagliari, 09124 Cagliari, Italy
| | - Sofia Vassallo
- Scuola Specializzazione Allergologia e Immunologia Clinica, Universita’ di Cagliari, 09124 Cagliari, Italy
| | - Angelo Scuteri
- S.C. di Medicina Interna, Policlinico Universitario Monserrato “Duilio Casula”—AOU di Cagliari, 09123 Cagliari, Italy
- Dipartimento Scienze Mediche e Sanita’ Pubblica, Universita’ di Cagliari, 09124 Cagliari, Italy
- Correspondence:
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Yadav P, Bari MA, Saha A, Yadav S, Khan AH. Partial Sheehan's syndrome with abdominal tuberculosis presented with pancytopenia and fluctuating thyroid profile: a case report. Ann Med Surg (Lond) 2023; 85:506-13. [PMID: 36923749 DOI: 10.1097/MS9.0000000000000244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/24/2022] [Indexed: 03/06/2023] Open
Abstract
Sheehan's syndrome is a well-recognized cause of panhypopituitarism secondary to pituitary apoplexy, followed by postpartum hemorrhage. Depending upon the degree of ischemic injury, it can be either partial or complete. Case presentation We report an interesting case of a 35-year-old woman admitted to our hospital with complaints of abdominal distension, which was later presumed to be due to disseminated tuberculosis (TB) after excluding the possible differentials. During the treatment course, she was going through repeated attacks of hypovolemic shock and hypoglycemia due to adrenocortical insufficiency. This, along with the history of prolonged amenorrhea 4 years back due to severe postpartum hemorrhage in her last pregnancy, has led us to our diagnosis of partial Sheehan's syndrome. After 1 month of starting steroid and anti-TB therapy, it was quite surprising when she presented with features of pancytopenia and antitubercular drug-induced hepatitis. Discussion Sheehan's syndrome may have a varying degree of presentation depending upon the degree of damage to the pituitary gland, which includes amenorrhea, lactation failure, adrenocortical insufficiency, hyponatremia, hypoglycemia, as well as pancytopenia in some rare instances The hormone panel especially the thyroid profile should be monitored carefully. Such cases are often challenging to deal with because of their varying degrees of presentation and the delay in diagnosis due to a lack of clinical suspicion. Conclusion Therefore, we believe that this rare presentation of pancytopenia in Sheehan's syndrome with fluctuating thyroid profile and abdominal TB in the background will let clinicians approach such a rare disease differently.
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Onsongo S, Mulwa E, Mutiso B. A patient with leishmaniasis presenting with longstanding pancytopenia and hepatosplenomegaly. Clin Case Rep 2023; 11:e6940. [PMID: 36789304 PMCID: PMC9914078 DOI: 10.1002/ccr3.6940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/13/2023] [Accepted: 01/27/2023] [Indexed: 02/12/2023] Open
Abstract
Leishmaniasis is a common cause of pancytopenia and hepatosplenomegaly in tropical and subtropical regions. A high index of suspicion is required to diagnose and manage patients with leishmaniasis. Travel history should always be elicited in a patient with suggestive clinical presentation.
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Mahmoud A, Ghrewati M, Kania B, Naseer M, Kapoor A, Michael P. Aleukemic Acute Promyelocytic Leukemia: How Concomitant HIV, Hepatitis C, and Chronic Alcohol Use Disorder May Have Hidden an Underlying Malignancy. Am J Case Rep 2023; 24:e938086. [PMID: 36760096 PMCID: PMC9924157 DOI: 10.12659/ajcr.938086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute promyelocytic leukemia (APL) is a rare subtype of acute myeloid leukemia (AML) and is characterized by a genetic translocation affecting the retinoic acid receptor-alpha gene, leading to blockage in the differentiation of granulocytic cells. The accumulation of promyelocytes in bone marrow leads to cytopenias and life-threatening coagulopathies. Definitive diagnosis is made with bone marrow biopsy. Differentiation of APL from other leukemias is important to appropriately treat with all-trans retinoic acid (ATRA) and arsenic trioxide. Patients with HIV are at a higher risk to develop AML. This article identifies how multiple comorbidities and social factors can contribute to difficulties in diagnosing AML. CASE REPORT We present a 67-year-old man with a past medical history of hypertension and substance use disorder who presented with progressive exertional dyspnea and was found to have HIV, chronic hepatitis C, and APL with pancytopenia. His bone marrow biopsy confirmed AML. This was a case of co-existing HIV and aleukemic leukemia. CONCLUSIONS APL can present with pancytopenia, weakness, failure to thrive, or bleeding complications, which can be similar to presentations of those diagnosed with HIV. Diagnosis of APL can be differentiated between hypergranular and hypogranular; our patient demonstrated APL with only 52% blasts, which can make for a challenging diagnosis. Given increased mortality of APL, immediate ATRA therapy is warranted. Aleukemic leukemia is a rare presentation typically accompanied by skin manifestations. Our case highlights the importance of having high clinical suspicion for malignancy in patients with comorbidities that can interfere with the classic presentation of leukemia.
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Affiliation(s)
- Anas Mahmoud
- Department of Medicine, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Moutaz Ghrewati
- Department of Hematology-Oncology, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Brooke Kania
- Department of Medicine, St. Joseph’s University Medical Center, Paterson, NJ, USA,Corresponding Author: Brooke Kania, e-mail:
| | - Minha Naseer
- Department of Medicine, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Ashima Kapoor
- Department of Hematology-Oncology, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Patrick Michael
- Department of Medicine, St. Joseph’s University Medical Center, Paterson, NJ, USA
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Rahmathullah I, Umakanth M, Singhapathirane S. Non-myeloproliferative Pancytopenia: A Rare Presentation of Thyrotoxicosis. Cureus 2023; 15:e35076. [PMID: 36945271 PMCID: PMC10024633 DOI: 10.7759/cureus.35076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/18/2023] Open
Abstract
Thyrotoxicosis-induced pancytopenia is a rare manifestation. The practical challenge is to differentiate thyrotoxicosis-induced pancytopenia from the side effects of anti-thyroid treatment following the commencement of treatment. Although some of the possible underlying pathogeneses have been reported, the complete mechanisms remain unclear concerning pancytopenia in uncontrolled thyrotoxicosis. Thyrotoxicosis-induced pancytopenia is completely reversible with the administration of anti-thyroid drugs at an appropriate time and regular follow-up to prevent further recurrence.
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Nogueira F, Brito IC, Pereira CV, Marques JC, Ferreira E, Carneiro A. Haemophagocytic Lymphohistiocytosis Associated With Anaplastic Large-Cell Lymphoma in a Young Woman. Cureus 2023; 15:e35130. [PMID: 36945277 PMCID: PMC10026187 DOI: 10.7759/cureus.35130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 02/19/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis is a syndrome of excessive immunological activation that can be triggered by various diseases, including haematological cancers. We report a case of a 25-year-old woman presenting with constitutional symptoms and a painful thoracic mass of four months duration. Laboratory exams showed pancytopenia, hypertriglyceridemia and extremely high serum ferritin levels. A whole-body computed tomography (CT) scan revealed splenomegaly and highlighted the mass on the deep tissues of the left breast; the biopsy was compatible with anaplastic large-cell lymphoma. Additionally, a bone marrow biopsy revealed haemophagocytosis, fulfilling the criteria for associated haemophagocytic lymphohistiocytosis. The patient was quickly sent for chemotherapy followed by autologous haematopoietic cell transplantation. She achieved a complete metabolic response and has been in clinical remission after nearly four years of follow-up. We emphasise the benefit of a timely diagnosis and intervention which were the keys to success in this case.
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Affiliation(s)
- Fernando Nogueira
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Isabel C Brito
- Clinical Haematology, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Catarina V Pereira
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - José C Marques
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Ester Ferreira
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Ana Carneiro
- Clinical Haematology, Centro Hospitalar Universitário de São João, Porto, PRT
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Gao X, Wang Y, Wang R, ‐Yuan J, Yang J, Zhang X, Li J. A rare case of pancytopenia causing- Sheehan's syndrome: Case report and literature review. Clin Case Rep 2023; 11:e6827. [PMID: 36703770 PMCID: PMC9871400 DOI: 10.1002/ccr3.6827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 11/13/2022] [Accepted: 12/08/2022] [Indexed: 01/26/2023] Open
Abstract
We describe the case of a 58-year-old woman who was presented with pancytopenia and hypofibrinogenemia. Treatment with iron supplementation was not satisfactory. Physical findings and a history of a massive postpartum hemorrhage suggested Sheehan's syndrome(SS). After thyroxine and glucocorticoid replacement therapy, the blood cell count improved. SS is a rare etiology of hemocytopenia, of which hematologists need to be aware. We conclude that hormonal therapy can produce full hematological recovery.
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Affiliation(s)
- Xiao‐Han Gao
- Department of HematologyHebei General HospitalShijiazhuangChina
| | - Yuan Wang
- Department of OncologyHebei Chest HospitalShijiazhuangChina
| | - Rui‐Cang Wang
- Department of HematologyHebei General HospitalShijiazhuangChina
| | - Jun ‐Yuan
- Department of HematologyHebei General HospitalShijiazhuangChina
| | - Jie Yang
- Department of HematologyHebei General HospitalShijiazhuangChina
| | - Xiao‐Xia Zhang
- Department of HematologyHebei General HospitalShijiazhuangChina
| | - Jie Li
- Department of HematologyHebei General HospitalShijiazhuangChina
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