Registration of essential medicines in Kenya, Tanzania and Uganda: a retrospective analysis

OBJECTIVES

To audit national drug registers (NDRs) in Kenya, United Republic of Tanzania and Uganda with respect to national Essential Medicine Lists (EMLs) and to conduct an analysis of highly registered products including a sub-analysis of highly registered antimicrobial products.

DESIGN

Retrospective analysis of registration of essential medicines and medicinal products on NDRs as of February 2018.

SETTING

Not applicable.

PARTICIPANTS

None.

MAIN OUTCOME MEASURES

Registration status of essential medicines by country, essential medicine status of registered products by country and medicines with more than 50 registrations across all three countries.

RESULTS

A high proportion of essential medicines are not registered: Kenya 28% (175/632), United Republic of Tanzania 50% (400/797) and Uganda 40% (266/663). Of registered products on the NDRs, more than half are not essential: Kenya 71% (4350/6151), United Republic of Tanzania 64% (2278/3590) and Uganda 58% (2268/3896). When the three NDRs were combined, there were 42 medicines with over 50 registered products, accounting for 30% (4153/13637) of products, many of which were non-essential.

CONCLUSIONS

Non-registration of essential medicines is a barrier to availability. Over-registration of medicines, particularly non-essential medicines, diverts regulatory resources towards registering non-priority and, sometimes, clinically sub-optimal medicines. The East African Community Medicines Registration Harmonization Project has the potential to improve access to key medicines if registration of essential medicines is prioritised and registration of non-essential medicines is restricted.

Sponsorship of Australian and New Zealand medical societies by healthcare companies: an observational study

Objectives

To examine sponsorship of Australian and New Zealand medical societies by healthcare companies and whether societies have policies to deal with conflicts of interest.

Design

Cross-sectional study conducted in March 2022.

Setting

Australia and New Zealand

Participants

Medical societies in both countries.

Main outcome measures

The percent of medical societies that list sponsorship from healthcare companies on either their home webpages or the webpages of their annual meetings and/or that issue prospectuses to potential sponsors. The percent of societies with sponsorship that also have policies about their interactions with their sponsors. Whether societies feature their sponsors’ logos on their webpages and have hyperlinks to sponsors’ webpages and what percent of societies' annual revenue comes from sponsorships.

Results

Ninety-two medical societies were identified. Sixty-two had healthcare company sponsorship and 10 of the societies with sponsorship had policies to deal with interactions with their sponsors. Fifty-four societies displayed the logos of their sponsors on their home webpages and/or the webpages of their annual meetings. Only 6 societies provided enough information to calculate what percent of their revenue comes from sponsorships. For 5 of the 6 the percent was well below 50%.

Conclusions

The acceptance of sponsorships from healthcare companies by Australian and New Zealand societies is common and few societies have policies to deal with these relationships. In general, societies appear to get only a small percent of their annual revenue from sponsorships.

Metastatic chordoma with pancreatic disease and response to imatinib

A 45-year-old woman presented with a left-sided neck swelling following treatment a year prior for cervical spine chordoma. She had initially been managed surgically with a cervical vertebrectomy and a course of proton beam therapy. Although there had been a degree of residual tissue, her disease remained stable radiologically and clinically. Repeat MRI demonstrated an increasing left paravertebral mass and a head of pancreas metastasis, which shared pathological characteristics with chordoma. Given the advanced metastatic nature of her disease, imatinib was offered with a palliative intent. While waiting for treatment she developed a spinal cord compression, managed with radiotherapy. She commenced imatinib and her disease remained stable for 9 months before progressing clinically and radiologically. This case demonstrates an unusual pattern of metastatic chordoma and provides further rationale for imatinib in such patients.

Prurigo excoriée treated with low dose naltrexone

A 53-year-old woman presented with a 25-year history of acne excoriée and prurigo excoriée. Her symptoms began in 1988 coinciding with her husband's death from a brain tumour when she was 27. The pruritus affected her quality of life and disturbed her sleep. She had scarring on her face and body resulting from persistent scratching. The pruritus proved refractory to treatment despite a multi-modal treatment approach including multiple topicals, phototherapy and systemic agents such as isotretinoin, antibiotics, anxiolytic agents and neuromodulators. She was extremely frustrated that various treatments had been ineffective at controlling the itch-scratch cycle. She was commenced on low dose naltrexone (LDN), 3 mg nocte, and she became itch free within a few weeks. She reports that the LDN has had a beneficial impact on her quality of life.

MELAS syndrome: an acute stroke-like episode complicated by renal tubular acidosis

MELAS, a mitochondrially inherited multisystem disorder, can present with acute stroke-like episodes. The literature thus far supports the use of L-arginine therapy in acute MELAS flares to alleviate and shorten the duration of symptoms. This is the case of a patient who presented with ataxia and worsening confusion on a background of genetically confirmed MELAS syndrome. In this instance, intravenous L-arginine therapy, along with corticosteroids, was administered in keeping with best practice. However, in a metabolically vulnerable patient, L-arginine therapy resulted in a further deterioration in his clinical status and the development of a non-anion gap metabolic acidosis.

Paradoxical refractory hypotension following adrenaline administration in a patient taking clozapine

Clozapine is a potent antipsychotic commonly used for refractory schizophrenia. Adverse effects are well recognised including constipation, intestinal obstruction, agranulocytosis and cardiomyopathy. We present a case of paradoxical refractory hypotension following epinephrine administration in a patient taking clozapine. A psychiatric inpatient who had been taking clozapine for many years developed paralytic ileus and obstruction requiring surgical intervention. Following initiation of epinephrine administration intraoperatively he developed refractory hypotension which improved only when epinephrine was weaned off. This effect is likely due to uninterrupted β2-agonist activity in the presence of clozapine-induced α-blockade. Clinicians need to have greater awareness of this serious interaction and avoid the use of epinephrine in patients taking clozapine.

Sustained response to imatinib in patient with extraskeletal myxoid chondrosarcoma and novel KIT mutation

A 55-year-old woman presented with a 3-month history of right groin swelling, discomfort and impaired mobility. On examination, a palpable mass was noted both to the right of midline in the lower abdomen and in the right groin. MRI of the pelvis showed two masses involving the anterior abdominal wall and right groin, as well as lymph node involvement. CT imaging revealed multiple bilateral pulmonary metastases. Pathology demonstrated a myxohayline stroma morphology. Tumour was also notable for NR4A3 gene region rearrangement and mutation in KIT exon 11 at position c.1669 T>G. Based on these findings, she was diagnosed with extraskeletal myxoid chondrosarcoma (EMC). The patient has been on imatinib, a tyrosine kinase inhibitor with activity against KIT, for 3 years with stable disease. Metastatic EMC is generally treated with surgical resection and perioperative radiation therapy with adjuvant chemotherapy and is associated with poor prognosis.

Early presentation of pembrolizumab-associated pneumonitis

Pembrolizumab is a selective anti-PD-L1 humanised monoclonal antibody approved by the Food and Drug Administration for treating multiple cancers, including cervical cancer, non-small cell lung cancer (NSCLC), renal cell carcinoma, bladder cancer, and squamous head and neck cancer. Pneumonitis is a rare but known complication of pembrolizumab treatment for NSCLC. The median time frame of its appearance is 2.8 months. However, we present a case of pneumonitis appearing within 48 hours. The patient presented with rapidly progressive respiratory failure, and imaging demonstrated diffuse bilateral patchy involvement of the upper lung lobe and pre-hilar regions, which likely indicate pneumonitis. Because of likely grade 3 pneumonitis, he was treated with steroids and showed immediate improvement of symptoms. Repeated CT imaging showed resolution of bilateral patchy infiltrates. He was discharged to the rehabilitation unit. Rapid recognition of pneumonitis as a side effect of pembrolizumab is important because early treatment can help prevent respiratory failure and possible death.

Adult Xp11.2 translocation renal cell carcinoma managed effectively with pazopanib

Xp11.2 translocation renal cell carcinoma (TRCC) is a rare and aggressive variant of renal cell carcinoma (RCC) when presenting in adults. We report a case of a man in his early 40s who was diagnosed with stage III Xp11.2 TRCC and underwent radical nephrectomy. Seven months following the surgery, an adrenal nodule and bilateral pulmonary nodules were discovered. He underwent cryoablation of the adrenal nodule and systemic treatment with daily pazopanib. He displayed stable disease for approximately 6 years. Following this period, multiple hospitalisations interrupted daily pazopanib therapy resulting in progression of disease. His regimen was then changed to ipilimumab and nivolumab, followed by current daily therapy with axitinib. The patient now shows stable disease in his 10th year after diagnosis. This case study demonstrates the efficacy of pazopanib for metastatic Xp11.2 TRCC and warrants further investigation to supplement the guidelines regarding the use of targeted therapy for TRCC.

Acanthamoeba scleral abscess reoccurring after penetrating keratoplasty

Two months following penetrating keratoplasty for Acanthamoeba keratitis, a 76-year-old man was referred due to inability to wean high-dose topical steroids. Despite a very healthy graft and minimal pain, a scleral abscess involving three clock hours of the superior conjunctiva was present. The patient underwent conjunctival and scleral excision of the area of apparent infection with adjuvant mitomycin C and double freeze-thaw cryotherapy treatment followed by amniotic membrane graft. Recurrence was confirmed with PCR. Following a multimonth regimen of oral voriconazole and topical polyhexamethylene biguanide, chlorhexidine and moxifloxacin, the patient was weaned from all anti-infectious agents. After cataract surgery and scleral lens fitting, the patient is now 20/20 in the affected eye. This case highlights the need for judicious use of immunosuppressive agents as well as the necessary vigilance to monitor for recurrence with Acanthamoeba infection. It also represents the first reported use of adjuvant mitomycin C and double freeze-thaw cryotherapy for treatment of Acanthamoeba scleral abscess.

Case of vaso-occlusive retinopathy in Kikuchi-Fujimoto and lupus overlap syndrome

A 35-year-old woman presented with a constellation of systemic symptoms: rashes, weight loss, arthralgia and mouth ulcers. Six months afterwards, she experienced bilateral and sequential reduction in vision, and was found to have bilateral vaso-occlusive retinopathy, with critical macular ischaemia in the left eye. Her serological markers were consistent with a diagnosis of lupus. A lymph node biopsy confirmed Kikuchi-Fujimoto disease, a benign condition of unknown cause characterised by fever, cervical and axillary lymphadenopathy. Given that this overlap syndrome was associated with a number of systemic features and had affected the eyes, an immunosuppressive regime with rituximab was considered prudent. This rendered her vasculitis stable and non-progressive, and there were signs of partial retinal microvasculature recovery on optical coherence tomography angiography. There is increasing evidence of an overlap between Kikuchi-Fujimoto disease and systemic lupus erythematosus, which is associated with vaso-occlusive retinopathy. In these instances, a multidisciplinary approach is warranted, with consideration of appropriate treatment in order to prevent harmful sequelae of vasculitis. Our treatment with rituximab abated the disease process, although close follow-up is paramount to monitor results and side-effects of treatment.

Rapid and Durable Response With Nab-Sirolimus After Everolimus Failure in a Patient With Perivascular Epithelioid Cell Tumors (PEComas) of the Uterus

Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal tumors with a natural history ranging from indolent benign lesions to ones with an aggressive clinical course including distant metastases. Recent reports have suggested that mTOR inhibitor sirolimus and related drugs show some benefit in non-tuberous sclerosis complex PEComas. However, therapeutic options for patients who progress on sirolimus are very limited. We describe a patient with metastatic uterine PEComa, who progressed on mTOR inhibitor everolimus but had a rapid and durable response to nab-sirolimus.

A Comparison of Seizure Prophylaxis: Phenytoin Versus Levetiracetam

Phenytoin and levetiracetam are both antiepileptic drugs (AEDs) used for seizure prophylaxis. However, to date, there is a paucity of literature comparing their relative efficacies. In this narrative review, we seek to determine if there is greater advantage between the two AEDs, levetiracetam and phenytoin. Phenytoin is the more traditional AED of the two as it has been medically used for a much longer time than levetiracetam. However, levetiracetam, the newer AED of the two, has fewer side effects than phenytoin and fewer drug-drug interactions. Although past studies have aimed to compare the efficacy of phenytoin versus levetiracetam, there is no clear consensus as to if there is a clinical advantage to one over the other. Here, we have analyzed several studies published between 2013 and 2020 in the hopes of having a better understanding of which AED is more efficient in preventing seizures. Many factors can contribute to determining which AED is the better fit for patients, including pricing, risk for adverse drug effects, and level of patient monitoring. After analysis of past research, the more advantageous AED still remains unclear. Future research must be conducted that involve large patient populations, stratifying age populations, and studies analyzing cost-effectiveness to clearly determine if there is indeed a more advantageous AED between levetiracetam and phenytoin.

Systemic reaction during intradermal skin tests with beta-lactams

Beta-lactam (BL) antibiotics are the most frequent cause of drug hypersensitivity in children, inducing both immediate and non-immediate reactions. Here we report a case of a 4-year-old child with a disseminated maculopapular exanthema 7 days after the first dose of amoxicillin-clavulanate, referred to our paediatric allergy department. Skin prick tests were negative. Intradermal tests were performed and, after 10 hours, indurated wheals larger than 10×10 mm with progressive erythema and disseminated maculopapular eruption were developed, related to amoxicillin and amoxicillin-clavulanate. Systemic reactions to BL skin tests are rarely reported and the majority are immediate reactions. This case illustrates a rare example of a non-immediate systemic reaction to intradermal tests, underlying the importance of skin testing before drug provocation tests in cases of moderate to severe non-immediate reactions.

Treatment of unexplained coma and hypokinetic-rigid syndrome in a patient with COVID-19

The COVID-19 pandemic has dealt a devastating blow to healthcare systems globally. Approximately 3.2% of patients infected with COVID-19 require invasive ventilation during the course of the illness. Within this population, 25% of patients are affected with neurological manifestations. Among those who are affected by severe neurological manifestations, some may have acute cerebrovascular complications (5%), impaired consciousness (15%) or exhibit skeletal muscle hypokinesis (20%). The cause of the severe cognitive impairment and hypokinesis is unknown at this time. Potential causes include COVID-19 viral encephalopathy, toxic metabolic encephalopathy, post-intensive care unit syndrome and cerebrovascular pathology. We present a case of a 60 year old patient who sustained a prolonged hospitalization with COVID-19, had a cerebrovascular event and developed a persistent unexplained encephalopathy along with a hypokinetic state. He was treated successfully with modafinil and carbidopa/levodopa showing clinical improvement within 3-7 days and ultimately was able to successfully discharge home.

Concurrent terbinafine-induced acute generalised exanthematous pustulosis and hepatitis

Terbinafine is a commonly used antifungal medication. Its side effects, while widely known, are rarely described and can be missed by the medical community. We present a 55-year-old woman who visited her primary care physician with onychomycosis. She started treatment with terbinafine, and 1 week later developed a rash in the left flank that extended to the chest, back, and upper part of lower extremities. Laboratory results showed elevated liver enzymes. A treatment with steroids did not improve the rash and she was admitted to our institution. She was started with intravenous dexamethasone, topical hydrocortisone and triamcinolone. Seven days later the liver enzymes normalised, and the rash resolved on the chest and back. Our patient had concurrent acute generalised exanthematous pustulosis and hepatitis that together has been very rarely associated with terbinafine.

Lamotrigine-associated hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening disorder of excessive immune activation. It is mostly seen in the paediatric population and is rarely observed in adults. HLH can be inherited or acquired and is commonly triggered by activation of the immune system by an underlying viral infection or in immune system deficiency such as malignancy or underlying rheumatological disease. HLH is a difficult entity to diagnose due to the rarity of this disorder, variable clinical presentation and non-specific clinical and laboratory findings. HLH carries a high mortality if left untreated, and therefore prompt diagnosis and initiation of immunosuppressive, immunomodulatory and cytostatic medications are critical to improve survival in affected patients. Here, we present a case of lamotrigine-associated HLH. To our knowledge, only eight other cases of lamotrigine-associated HLH have been reported in adult patients.

Salicylate toxicity from chronic bismuth subsalicylate use

A 79-year-old man presented to the emergency department with a 1-week history of worsening confusion, falls and hearing impairment. An initial workup for infectious, metabolic and structural causes was unrevealing. However, further history discovered that he had been ingesting one to two bottles of Pepto-Bismol (bismuth subsalicylate) daily for gastro-oesophageal reflux symptoms. On his second day of admission, the plasma salicylate concentration was 2.08 mmol/L (reference range 1.10-2.20 mmol/L), despite no sources of salicylate in hospital. He was diagnosed with chronic salicylate toxicity and Pepto-Bismol use was discontinued. The patient was treated supportively with isotonic intravenous fluids only and plasma salicylate concentration fell to less than 0.36 mmol/L. Concurrently, all his symptoms resolved. This case highlights the potential adverse effects of over-the-counter medications. The diagnosis of chronic salicylate toxicity is challenging, specifically in the elderly and in undifferentiated presentations, as it can be missed if not suspected.

Haemorrhagic nasal polyp mimicking melanoma in an 83-year-old on rivaroxaban

An 83-year-old woman presented with rapid onset unilateral nasal obstruction after sneezing. She had a history of hypertension and atrial fibrillation, and was on rivaroxaban. Examination revealed a dark red polypoidal lesion completely obstructing the left nostril. She underwent CT and MRI, and proceeded to urgent excision biopsy of the lesion. Intraoperative appearance was in keeping with a haemorrhagic polyp arising from the nasal septum. Histology revealed haematoma within a layer of nasal mucosa. There was no evidence of haemangioma underlying the polyp. Our literature search has identified this case as the first described haemorrhagic polyp of the nasal septum. It is likely that rivaroxaban contributed to the formation of this haemorrhagic polyp, and it is important to differentiate benign haemorrhagic lesions from malignant conditions such as melanoma. Similar cases may become more common in the future as the proportion of the population on anticoagulants increases.

Vajra Bhasma, Ayurvedic medicine: a rare and unusual cause of Lyell's syndrome and its successful management

Toxic epidermolysis necrosis (TEN) or Lyell syndrome is a potentially life-threatening immunological adverse skin disease, which mostly occurs secondary to the intake of an offending drug. It commonly manifests as a widespread exfoliating bullous lesion in skin and mucous membrane mimicking superficial burns and may result in hypovolemic and/or septic shock. Authors report an unusual case of Lyell's syndrome in a 42-year-old woman, secondary to the intake of Ayurveda medicine 'Vajra Bhasma' (Diamond Ash) prescribed by an Ayurveda physician for treatment of her trigeminal neuralgia. After 8th day of continuous medication intake, she had prodromal illness and rapidly developing exfoliative skin lesion extended over 80% of total body surface area, breathing difficulty, dizziness and anuria. The case was successfully managed by timely diagnosis, adequate hydration and administration of immunoglobulins. After 17 days, the skin epithelium regenerated, and she improved clinically with some depigmented lesions at discharge, which were normalised without any sequel during her further follow-up visits in hospital. Identification and withdrawal of the suspected drug, adequate resuscitation and early immunoglobulin administration are critical in management of TEN.

Vasospasm induced myocardial ischaemia secondary to sumatriptan use

Certain medications have been implicated in causing acute myocardial infarctions (AMI). Sumatriptan, a medication usually prescribed for acute migraine and cluster headaches has been documented as potentially causing coronary vasospasm, thereby leading to MI. This is usually seen in patients with strong risk factors for coronary artery disease (CAD) or in those with established CAD. Most cases thus far have been reported in patients using the subcutaneous preparation of sumatriptan. Here, we present a case of a patient without prior risk factors for CAD and angiographically unremarkable coronary arteries who presented with evidence of an AMI after oral sumatriptan use for migraines.

Uneventful case of COVID-19 in a kidney transplant recipient

Kidney transplant recipients have been reported at a particularly high risk of severe COVID-19 illness due to chronic immunosuppression and coexisting conditions. Yet, here we describe a remarkably mild case of COVID-19 in a 62-year-old female who had a kidney transplantation 10 years earlier due to autosomal dominant polycystic kidney disease. The patient was admitted for 1 day; immunosuppressive therapy with tacrolimus and low-dose prednisolone was continued; and the patient recovered successfully without the use of antiviral agents or oxygen therapy. The case demonstrates that kidney transplant recipients are not necessarily severely affected by COVID-19. Withdrawal of immunosuppressive therapy could be associated with poorer outcomes and should not be implemented thoughtlessly.

Paediatric porphyria and human hemin: a treatment challenge in a lower middle income country

Here, we report a case of a 15-year-old girl who presented to the emergency department with symptoms of abdominal pain, nausea, vomiting and seizures. She was diagnosed with acute intermittent porphyria. Treatment was started by removing all porphogenic drugs, providing high glucose intake (oral and intravenous), which initially resulted in good clinical outcomes. However, she deteriorated again and also developed neurological manifestation (paraplegia) for which she required mechanical ventilation because of acute respiratory failure. This time she was initiated on human hemin for four consecutive days. After 2 days of therapy, her porphobilinogen levels decreased to 50% of the initial raised value. Increased lactic acid and blood urea nitrogen were the two side effects observed after the treatment, with no apparent signs of acute kidney injury. To the best of our knowledge, in paediatric population, this is the first reported case of treatment of acute intermittent porphyria with human hemin in Pakistan.

Bivalirudin resistance in a patient on veno-venous extracorporeal membrane oxygenation with a therapeutic response to argatroban

A 48-year-old male patient requiring extracorporeal membrane oxygenation (ECMO) support for hypoxaemic respiratory failure failed to achieve therapeutic anticoagulation with bivalirudin after continuous dose escalations, and continued to have recurrent fibrin stranding in the circuit over a 6-day course of treatment. Suspecting bivalirudin resistance, the patient was transitioned to argatroban and achieved a therapeutic response in less than 24 hours. The case describes the challenges of anticoagulation in ECMO supported patients. The interplay between bivalirudin metabolism, renal replacement therapy, and immunological effects leading to a heparin-like-effect, inflammatory mediators, and thrombotic burdens may all impact the clinical effect during bivalirudin therapy. The structural biochemistry of thrombin and bivalirudin likely plays a role in the presented patient's successful response to argatroban. Bivalirudin may fail at achieving therapeutic anticoagulation in patients with genetic thrombin mutations or structural defects that alter the binding pockets at the thrombin exosites.

Vocal cord surgery and pharmacological treatment of a patient with HPV and recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is caused by persistent infection of the respiratory epithelium by human papillomavirus (HPV), especially HPV 6 and 11. We present a case of surgically treated RRP. The main purpose of our protocol is to remove the lesions with a non-aggressive surgical technique and prevent recurrences with the use of cidofovir for local infiltrations in multiple sessions. We use low-power energy CO₂ laser, directed towards the upper part of the vocal cord, to determine a retraction of the mucosa with consequent coverage of the epithelium of the free edge. The aim of this technique is to treat and stop the formation of synechia of the anterior commissure and the free margin of the vocal cords in the anterior commissure. After 8 years follow-up, there are no signs of recurrence of the disease. The voice had a net improvement confirming the effectiveness of the protocol.

Mepolizumab rescue therapy for acute pneumonitis secondary to DRESS

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome represents a severe adverse drug reaction driven by eosinophilia. Treatment is focused on withdrawal of medication, supportive care and immunosuppression such as high-dose corticosteroid therapy. Here we report a 56-year-old male patient who initially presented with breathlessness and eosinophilia, subsequent development of respiratory failure and admission to ITU for non-invasive ventilation. The patient continued to deteriorate despite high-dose prednisolone and methylprednisolone. Other causes of hypereosinophilia were normal. He was diagnosed with DRESS syndrome secondary to pregabalin and was treated with subcutaneous mepolizumab. We observed the rapid resolution of eosinophilia and clinical improvement; the patient was discharged home within a month of administration. This represents the successful use of mepolizumab in the acute setting of pulmonary failure secondary to DRESS. A similar approach could be adopted in other acute conditions with refractory eosinophilic inflammation where standard steroid therapy has failed.

A fatal case of levamisole induced bone marrow failure

A 20-year-old college student presented with high grade, intermittent fever for 10 days associated with blood stained loose stools after taking tablet levamisole for 17 days for vitiligo vulgaris. He was febrile, had a toxic appearance and appeared pale. Investigations showed neutropaenia with thrombocytopaenia. Blood cultures were sterile and stool cultures did not grow any enteric pathogens. His bone marrow examination was suggestive of an aplastic anaemia. He was administered empirical antibiotics, granulocyte colony stimulating factor and platelet transfusions. However, his fever and blood stained stools persisted. A repeat bone marrow examination after 2 weeks still revealed a hypoplastic marrow. Hence, a diagnosis of a levamisole induced bone marrow failure was made. While being worked up for an allogeneic stem cell transplantation, he developed neutropaenic enterocolitis and refractory septic shock with carbapenem resistant Klebsiella pneumoniae and succumbed to his illness.

Encorafenib and binimetinib for the treatment of BRAF-mutated metastatic melanoma in the setting of combined hepatic and renal impairment

Inhibitors of BRAF, a gene coding a protein called B-raf, with or without inhibitors of MEK (MAPK/extracellular signal-regulated kinase) are often used as palliative treatment in BRAF-mutated metastatic melanoma. Recent data show improved progression-free survival with encorafenib with binimetinib, a newer BRAF/MEK inhibitor combination, compared with older agents, but there have been no reports of this treatment in the setting of renal and liver failure. We report a patient with disease-induced transaminitis and renal failure requiring dialysis who was successfully treated with encorafenib and binimetinib. His transaminitis improved and he was able to stop dialysis without any significant adverse effects during treatment, suggesting encorafenib with binimetinib may be used safely and effectively even in patients with end organ damage.

Retrograde ejaculation associated with quetiapine and treatment with low-dose imipramine

Sexual side-effects are common among those using antipsychotic medication and may result in poor compliance and reduced quality of life. Retrograde ejaculation (RE) has been described occurring with a number of antipsychotic medications (thioridazine, risperidone, iloperidone and clozapine) but there are no guidelines regarding management of antipsychotic-associated RE. Imipramine has been suggested as a treatment for antipsychotic-associated RE in one small study of patients prescribed thioridazine and a case series of patients prescribed iloperidone. Quetiapine is a commonly used antipsychotic and is thought to be associated with less sexual side-effects relative to other antipsychotic medications. This case report describes a 25-year-old man with first episode psychosis who developed RE during treatment with quetiapine which improved with low-dose imipramine. This is the first description of RE occurring with quetiapine and successful treatment of quetiapine-associated RE with imipramine.

Treatment of pulmonary blastomycosis with high-dose liposomal amphotericin B in a patient receiving extracorporeal membrane oxygenation

Blastomycosis-associated acute respiratory distress syndrome (ARDS) has a rare incidence. We report the case of a 29-year-old man with blastomycosis-associated ARDS receiving extracorporeal membrane oxygenation and managed with high-dose liposomal amphotericin B. This case illustrates the importance of timely diagnosis of pulmonary blastomycosis and appropriate dosing of antifungal therapy.

Dental management of patients with haemophilia in the era of recombinant treatments: increased efficacy and decreased clinical risk

Haemophilia is a hereditary X-linked recessive disorder caused by a deficiency of either clotting factor VIII (haemophilia A) or IX (haemophilia B). Conventional treatment is currently based on the use of either plasma derived or recombinant coagulation factors. This paper reports on the case of a patient with severe haemophilia who presented with mesial decay and interproximal tartar build-up, for which extraction and scaling to remove tartar deposits were indicated. Following extraction, the usual haemostasis techniques were applied, and postoperative prophylactic antihaemophilic treatment was indicated for 2 or 3 days. The patient presented with moderate bleeding for a few minutes immediately after the procedure. Administration of factor VIII before surgery as well as the patient’s favourable pharmacokinetic response allowed for an optimal result. This treatment has afforded patients with haemophilia a better quality of life, and safe and efficient access to invasive surgical procedures.

Reversible iatrogenic paraparesis secondary to masked hypokalaemia in thrombocytosis-associated pseudohyperkalaemia

An elderly patient who presented with recent recurrent falls was admitted, reporting inability to stand and recent acute diarrhoeal illness. Paraparesis was diagnosed but extensive investigations did not elucidate its cause. He had atherosclerotic cardiac and vascular disease, diabetes, hypertension, chronic kidney disease and pancreatectomy/splenectomy for a lesion that turned out to be benign. He was receiving multiple medications including kayexalate, which was started a few weeks prior, and the dose increased, due to hyperkalaemia up to 6.3 mEq/L. Although the postsplenectomy thrombocytosis was not striking (700×10⁹/L), spurious hyperkalaemia (pseudohyperkalaemia) was suspected when no cause of hyperkalaemia could be identified and widely fluctuating serum potassium levels were noted. Concurrent K⁺ determination in the serum and plasma revealed that the patient actually had significant masked hypokalaemia (2.4 mEq/L). Once kayexalate was stopped and normokalaemia (in plasma) achieved by replacement therapy, paraparesis completely resolved (5/5 muscle strength) and no more falls occurred after discharge.

Hydroxychloroquine-induced inverse psoriasis

A 65-year-old woman presented to our rheumatology clinic with pain and swelling of multiple joints of her hands. After a thorough evaluation, she was diagnosed with rheumatoid arthritis and was started on hydroxychloroquine therapy. A week later, she presented to our clinic with an acute condition and reported that after taking hydroxychloroquine for a few days she developed multiple rashes, most prominent at skin folds around her breasts, neck, axillae and buttocks. The rashes were characteristic of inverse psoriasis. Hydroxychloroquine was discontinued and the patient was started on methotrexate therapy that resulted in resolution of her rashes in a week.

Dantrolene is not the answer to 2,4-dinitrophenol poisoning: more heated debate

There has been a resurgence in the use of 2,4-dinitrophenol, C₆H₄N₂O₅ (DNP) recently as an illegal weight loss drug. We present a case of a healthy 25-year-old girl who took two tablets of DNP, purchased from an overseas online retailer. She was managed with aggressive, invasive cooling measures and 2.5 mg kg^-1 dantrolene. Despite this, her temperature continued to rise exponentially to 41.5°C. Cardiac arrest occurred and resuscitation was unsuccessful. To our knowledge, this is the first reported case of the ineffective use of dantrolene in acute DNP poisoning. We review the pathophysiology of DNP toxicity and argue that the use of dantrolene therapy is biochemically implausible, based on poor evidence and likely to be futile. We have contacted the UK National Poisons Information Service (NPIS/TOXBASE) to propose changes to the management of acute DNP toxicity.

Exclusively plant, whole-food diet for polypharmacy due to persistent atrial fibrillation, ischaemic cardiomyopathy, hyperlipidaemia and hypertension in an octogenarian

Polypharmacy is common and associated with negative health outcomes in the elderly. We report the case of an 82-year-old man with a history of polypharmacy due to coronary artery disease, myocardial infarction, ischaemic cardiomyopathy, hyperlipidaemia, hypertension and persistent atrial fibrillation who presented with memory loss, cognitive impairment, fatigue and weakness. His treatment plan included an exclusively plant, whole-food diet and moderate physical activity which resulted in a rapid reduction of hyperlipidaemia and high blood pressure and the discontinuation of statin, antihypertensive and beta blocker drug therapy. The patient also reported reversal of impaired cognition and symptoms associated with atrial fibrillation and ischaemic cardiomyopathy, including light-headedness, fatigue and weakness. This case demonstrates that dietary and lifestyle modifications have the potential to improve symptoms of cardiovascular disease and reduce polypharmacy along with associated negative consequences in the elderly.

Treatment dilemma for survivors of rituximab-induced bowel perforation in the setting of post-transplant lymphoproliferative disorder

Post-transplant lymphoproliferative disorder (PTLD) is a recognised complication of solid and haematopoietic stem cell transplant. It consists of a heterogeneous group of lymphoid neoplasms that arises secondary to post-transplant immunosuppression. Although there is no definite standard of care for the optimal treatment for PTLD, rituximab, a monoclonal antibody, with and/or without chemotherapy (usually CHOP=cytoxan, doxorubicin, vincristine, prednisone) has become a routine part of the treatment of any CD20 (+) PTLD, with response rates similar to chemotherapy with decreased toxicity. A rare and often lethal, complication of rituximab therapy for PTLD is bowel perforation secondary to tumour lysis of lymphoma involving the intestine. A small number of cases of bowel perforation have been reported, with very few documented survivors. The risk for recurrent perforation in the setting of ongoing rituximab treatment is unknown. There is sparse data supporting how to best treat the survivors.

Diffuse large B cell lymphoma with superimposed lung abscess: potential role for intracavitary fibrinolytic therapy through a percutaneous drain to facilitate lung abscess drainage

This is a case of primary pulmonary lymphoma presenting concurrently with superimposed lung abscess, managed with the assistance of intracavitary fibrinolytic therapy. A 28-year-old man presented with 2 months of persistent cough. He had a large lung abscess involving almost the entire right upper lobe. The mass continued to progress in spite of appropriate antibiotic administration. Given the extent of involvement, he was not a surgical candidate. A bronchoscopy with bronchoalveolar lavage and transbronchial biopsies demonstrated diffuse large B cell lymphoma. Initial cultures were positive for Group G Streptococci A CT-guided percutaneous drain was placed with initial purulent drainage that grew Prevotella and Streptococcus mitis; however, drainage quickly abated without adequate evacuation of the abscess cavity. To further optimise drainage in anticipation of chemotherapy administration, intracavitary fibrinolytic therapy including tissue plasminogen activator and deoxyribonuclease was attempted to better evacuate the infected space.

Bullous pemphigoid associated with ipilimumab therapy for advanced metastatic melanoma

Immunotherapy is now being routinely used in the management of many cancers. It is therefore vital that all clinicians are aware of the diverse array of cutaneous manifestations that can result from their use, which can vary from mild to life threatening.

Fatal interstitial lung disease caused by Panitumumab-containing chemotherapy regimen

Fatal interstitial lung disease (ILD) is one of the rare side effects of Panitumumab. Both fatal and non-fatal ILD have been reported mainly in the Japanese population. We report a case of a nonsmoking Caucasian man with the diagnosis of metastatic rectal cancer (K-RAS wild-type) who developed fatal ILD after receiving a Panitumumab-containing chemotherapy regimen. He initially presented with a locally advanced rectal cancer (T3N2M0) for which he received neoadjuvant chemoradiotherapy. Before the rectal surgery, he was found to have liver metastases which were considered potentially resectable. The decision was to delay the rectal surgery and to start systemic treatment. He was started on Modified De Gramont regimen (folinic acid and fluorouracil) plus Oxaliplatin with Panitumumab. Six months later, he underwent rectal surgery which showed a complete response. He continued on systemic treatment while awaiting liver metastasectomy. After three courses of Modified De Gramont plus Oxaliplatin with Panitumumab, he was admitted with few days’ history of increasing shortness of breath. High-resolution computed tomography of the lungs showed the features of interstitial pneumonitis. Despite receiving appropriate treatment, he continued to deteriorate and died due to respiratory failure.

Prolonged paralysis with atracurium use in a patient with Rubinstein-Taybi syndrome

Rubinstein-Taybi syndrome (RTS) is a rare autosomal dominant disorder that occurs due to a microdeletion of chromosome 16p13. The craniofacial abnormalities in these patients may pose a challenge for anaesthetist performing tracheal intubation. However, there are no known reported cases of drug interaction with non-depolarising muscle relaxant in patients with RTS. This young patient with RTS presented with an unexpected prolonged atracurium effect during the course of anaesthesia. After ruling out other possible causes, we have come to a conclusion that RTS itself could have played a role in the prolonged effect of atracurium. However, further studies will be needed to confirm this hypothesis. In the meantime, care should be used when using muscle relaxants in patients with RTS.

Unleashing the tiger - iatrogenic autoimmunity from cancer immunotherapy drugs

Immune checkpoint inhibitors can lead to the development of organ and non-organ specific immune related adverse events.

The first reported case of Atypical Femoral Fracture caused by daily ibandronate prescribed for bone metastases in breast cancer

A 55-year-old woman with bony metastatic breast cancer was commenced on daily ibandronic acid to prevent skeletal related events (SREs). Four years later, she began to experience new lower limb and groin pain with investigations leading to the suspicion of further metastatic spread to her left femur. While awaiting radiotherapy for this, she unfortunately tripped and fell sustaining a fracture to the proximal third of her left femur. Radiographic findings of her femur from both before and after the fall were suggestive of an atypical femoral fracture, presumed secondary to her bisphosphonate therapy rather than metastatic spread.