Graves' disease following administration of second dose of SARS-CoV-2 vaccine

The SARS-CoV-2 vaccines have had an overwhelming success in curbing the COVID-19 global pandemic, accounting for countless lives saved. Adverse reactions are inevitable, given the vast scale of vaccination required to mitigate future surges of COVID-19. Hyperthyroid disorders have been reported as potential adverse reactions to SARS-CoV-2 vaccines in two patients with Graves’ disease and a group of adults with subacute thyroiditis occurring in young women healthcare workers. We report a case of clinical Graves’ disease in a woman with a previously stable multinodular goitre that occurred 14 days following her second dose of Pfizer-BioNTech SARS-CoV-2 vaccine.

Acute interstitial nephritis secondary to vedolizumab

We present a patient with an acute kidney injury thought secondary to acute interstitial nephritis as a result of vedolizumab maintenance therapy for Crohn's disease. This appears to be a rare but serious side effect in patients receiving this treatment which clinicians should consider in the event of renal dysfunction.

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.

Case of sodium-glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis

Following non-elective orthopaedic surgery, a 61-year-old man with poorly controlled type 2 diabetes mellitus on empagliflozin developed high anion gap metabolic acidosis in the high-dependency unit. Metabolic acidosis persisted despite intravenous sodium bicarbonate, contributing to tachycardia and a run of non-sustained ventricular tachycardia. He was euglycaemic throughout hospital admission. Investigations revealed elevated urine and capillary ketones, and a diagnosis of sodium-glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis was made. He was treated with an intravenous sliding scale insulin infusion and concurrent dextrose 5% with potassium chloride. Within 24 hours of treatment, his arterial pH, anion gap and serum bicarbonate levels normalised. After a further 12 hours, the intravenous insulin infusion was converted to a basal/bolus regimen of subcutaneous insulin, and he was transferred to the general ward. He was discharged well on subcutaneous insulin 6 days postoperatively.

Avascular necrosis as a part of 'long COVID-19'

‘Long COVID-19’ can affect different body systems. At present, avascular necrosis (AVN) as a sequalae of ‘long COVID-19’ has yet not been documented. By large-scale use of life-saving corticosteroids in COVID-19 cases, we anticipate that there will be a resurgence of AVN cases. We report a series of three cases in which patients developed AVN of the femoral head after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 758 mg (400–1250 mg), which is less than the mean cumulative dose of around 2000 mg steroid, documented in the literature as causative for AVN. Patients were symptomatic and developed early AVN presentation at a mean of 58 days after COVID-19 diagnosis as compared with the literature which shows that it generally takes 6 months to 1 year to develop AVN post steroid exposure.

Adult multisystem inflammatory syndrome in a patient who recovered from COVID-19 postvaccination

Multisystem inflammatory syndrome in children has become a recognised syndrome, whereas a parallel syndrome in adults, multisystem inflammatory syndrome in adults (MIS-A), has not been well defined. Most cases occur several weeks following confirmed or suspected SARS-CoV-2 infection, but none have been reported in association with SARS-CoV-2 vaccines. Here we describe the case of a 22-year-old man, who received the inactivated SARS-CoV-2 vaccine 6 weeks following a mild COVID-19 infection. He presented after his second dose of the vaccine with a clinical picture of a multisystem inflammatory syndrome-like illness. Additionally, there was laboratory evidence of acute inflammation. The patient’s condition markedly improved after initiation of steroids. Whether the vaccine augmented an already-primed immunity from the infection and contributed to the occurrence of MIS-A is difficult to prove. Understanding the pathogenesis of this condition will shed light on this question and entail major implications on treatment and prevention.

Dysosmia and drug tolerance with use of venlafaxine

A 57-year-old woman presented with a 1-year history of major depressive disorder. She was started on venlafaxine XR 75 mg orally daily and a few days later developed severe dysosmia to foods she used to enjoy. She never had previous problems with smell or taste. At her 1-month follow-up, her depressive symptoms had improved, but she reported persistent dysosmia and was found to have associated weight loss due to decreased oral intake. She was advised to switch medications, but due to financial constraints she continued taking the same dose. At follow-up 48 days later, she reported complete resolution of her dysosmia and was eating normally again, but she had persistence of some depressive symptoms so her dose was gradually increased to venlafaxine XR 225 mg orally daily until her depressive symptoms and postmenopausal hot flashes were well controlled. There were no changes with continued use over the following 8 years.

Diffuse alveolar hemorrhage associated with ustekinumab treatment

PURPOSE

A case of diffuse alveolar hemorrhage (DAH) occurring as a reaction to ustekinumab therapy is reported.

SUMMARY

After starting ustekinumab for treatment of psoriatric arthritis, a 46-year-old female presented with flu-like symptoms and cough with blood-tinged sputum that had begun 1 week previously. Her initial computed tomography scan of the chest demonstrated bilateral ground-glass opacities. On bronchoscopy, the bronchoalveolar lavage (BAL) return became bloodier from sample 1 to samples 2 and 3. Her BAL fluid was more than 90% hemosiderin-laden macrophages, a finding consistent with DAH. We ruled out infectious etiologies and other common vasculitis conditions that can cause DAH. A diagnosis of ustekinumab-induced DAH was made due to a temporal relationship between initiation of the drug and the patient's presentation and the absence of infection and other alternate diagnosis. Prior case reports including ustekinumab-induced pneumonitis, interstitial lung disease with a granulomatous component, and lupus syndrome have been reported, with this being the first case of DAH in a patient undergoing treatment of psoriatic arthritis.

CONCLUSION

A 46-year-old woman developed DAH during ustekinumab treatment. Symptoms abated after drug discontinuation and supportive treament. Clinicians must remain mindful of this rare complication of ustekinumab use in order to avoid potential delays in appropriate DAH treatment.

Nitrous oxide-induced toxic leukoencephalopathy

Toxic leukoencephalopathy (TL) is characterised by an insult to the myelin of the cerebral white manner which can be attributed to a number of offending agents, including drugs of abuse. We report a case of a fit and well young man presenting to hospital with an altered mental state. It was subsequently determined that the patient inhaled a significant volume of nitrous oxide recreationally. Nitrous oxide is easily accessible and the second most consumed drug among young adolescents (16-24 years old). Following extensive investigations and brain imaging, the patient was subsequently diagnosed with TL. After a prolonged hospital admission, he went on to make a complete neurological recovery.

Quinidine hypersensitivity: a side effect of a forgotten antiarrhythmic

Quinidine is one of the oldest antiarrhythmics known. Over the years, its use has decreased along with its side effects. Our case describes a 69-year-old woman with recurrent resistant ventricular tachycardia on Quinidine and Amiodarone who presented with acute liver toxicity. Drug-induced liver toxicity was at the top of our differential diagnosis list. Taking multiple factors into consideration, a decision was made to discontinue Quinidine, the patient's symptoms and lab abnormalities resolved within 1 week, yielding the diagnosis of Quinidine hypersensitivity.

Case of paradoxical adverse response to mepolizumab with mepolizumab-induced alopecia in severe eosinophilic asthma

Recent years have seen an increase in use of mepolizumab and other biological therapies for the treatment of severe eosinophilic asthma. A few cases of paradoxical responses to mepolizumab therapy have now been reported and are hypothesised as being a response to immune complex formation. We present a case of mepolizumab-induced alopecia in a patient with paradoxical adverse response to mepolizumab given for severe eosinophilic asthma. We postulate this could be secondary to autoimmune mechanisms and that it could help herald poor response to treatment, thereby facilitating early identification of patients having paradoxical responses.

Diaphragm disease of the terminal ileum presenting as acute small bowel obstruction

Diaphragm disease (DD) of the small bowel is a rarely reported complication of non-steroidal anti-inflammatory drug (NSAID) use, characterised by diaphragm-like strictures, most commonly in the ileum, causing varying degrees of obstruction. It typically presents in the elderly, over many years with non-specific symptoms. Diagnosis is challenging, the majority of cases relying on histopathology for confirmation. Treatment involves NSAID cessation and surgery through a combination of stricturoplasties and/or segmental resection. Very rarely DD presents as a surgical emergency. A case presenting as acute small bowel obstruction (SBO) is described, initially diagnosed as adhesions, later confirmed to be DD of the terminal ileum following histopathological examination. Given the widespread use of NSAIDs and an ageing population, it is likely the incidence of DD will increase. It is, therefore, important that surgeons are aware of this disease entity and consider it as a potential diagnosis in patients presenting with acute SBO.

Rifampicin induced shock during re-exposure for treatment of latent tuberculosis

We present a case of a young Asian female with rheumatoid arthritis who received latent tuberculosis infection (LTBI) treatment prior to treatment with a biologic agent, and developed shock with resistant hypotension on re-exposure to rifampicin. We discuss the epidemiology, pathophysiology and management of rifampicin induced shock, concluding that clinicians should be aware of this rare, but potential adverse effect, and be aware that adverse reactions to rifampicin are more frequent during re-exposure or longer dosing interval regimes. The evidence for desensitisation following such a reaction is lacking and this approach is not currently recommended. We would suggest close collaboration between specialties prescribing immunosuppression and the tuberculosis team when LTBI treatment is required after a reaction, with patient involvement to discuss the risks and benefits of treatment options.

Electrocardiographic alterations and raised procalcitonin levels during anaphylactic shock

Anaphylaxis represents a systemic disease occurring after the exposure to an allergen. Drugs for the treatment of anaphylactic reactions (ie, corticosteroids and adrenalin) could induce autonomic alterations, such as tachycardia, hyperthermia, tachypnoea and leucocytosis. We describe the case of a 52-year-old woman presenting with a severe allergic reaction after the ingestion of amoxicillin-clavulanate. The occurrence of ECG alterations, laboratory abnormalities and procalcitonin (PCT) elevation will be discussed with particular emphasis on the possible misleading role of PCT during anaphylactic shock.

Terlipressin-induced ischaemic skin necrosis

Terlipressin is a commonly used drug in hepatology practice for the two most serious complications of cirrhosis, that is, acute oesophageal variceal bleed and hepatorenal syndrome. Acute-on-chronic liver failure (ACLF) is a medical emergency and is frequently associated with acute kidney injury (AKI). Two male patients with alcohol-induced ACLF with high MELD (Model for End-Stage Liver Disease) score presented with AKI. Both were treated with terlipressin infusion. There was no response to terlipressin in these sick patients, and further both patients developed ischaemic skin necrosis and succumbed to multiorgan failure. Continuous infusion of terlipressin is superior to bolus dosing, but we noted that continuous infusion might as well be associated with severe adverse effects in patients with a high MELD score. More extensive prospective studies, including patients with high MELD score, are required to ascertain the safety of terlipressin.

Opioid-induced hypoadrenalism resulting in fasting hypoglycaemia

An 18-year-old woman with a history of hollow visceral myopathy presented with a small-bowel obstruction. High-dose opioid analgesia was required subsequently during hospital admission. She suffered two episodes of documented fasting hypoglycaemia, despite adjustment of parenteral carbohydrate administration. Investigations for non-insulin-mediated hypoglycaemia revealed a low morning cortisol of 109 nmol/L and an inappropriately low Adrenocorticotropic hormone (ACTH) level of 2.2 pmol/L. A diagnosis of secondary adrenal insufficiency was confirmed on repeat cortisol and ACTH testing. The 250 µg short Synacthen test cortisol response was normal, suggestive of acute rather than chronic ACTH deficiency. This pattern was consistent after further opioid exposure. Adrenal recovery occurred shortly after opioid cessation. Opioid-induced hypoadrenalism is likely an under-recognised clinical entity with potentially serious adverse patient outcomes. There are reported cases involving commonly prescribed opioids including fentanyl and tramadol. However, we believe this is the first reported clinical case of acute transient opioid-induced secondary hypoadrenalism associated with fasting hypoglycaemia.

Pembrolizumab-induced autoimmune haemolytic anaemia and cholangitis

Increasing numbers of patients are now offered immunotherapy as part of their cancer treatment. These treatments, while often very effective, have a wide range of adverse effects that are distinct from those of traditional chemotherapy regimens. Thyroid disease, dermatological disease, colitis and pneumonitis are some of the most commonly reported immune side effects. We present a case of life-threatening de novo autoimmune haemolytic anaemia (AIHA) complicated by immune cholangitis induced by pembrolizumab. An 81-year-old woman with metastatic melanoma completed a two-year course of pembrolizumab in August 2018 and six weeks later presented to hospital with jaundice. Admission haemoglobin (Hb) was 91 g/L, rapidly decreasing to 31 g/L, at which point she required admission to the intensive care unit. AIHA is a rare but potentially life-threatening complication of checkpoint inhibitors and should be considered in patients presenting with anaemia during or after immunotherapy treatment.

Double trouble: ciclosporin-simvastatin coinduced rhabdomyolysis

A 73-year-old woman presented with an acute exacerbation of her long-standing psoriasis. Ciclosporin was commenced due to the severity of her symptoms resulting in remission within 2 weeks. Full blood count, urea and electrolytes following initiation of treatment were unremarkable, although she complained of muscle aches, which was attributed to her known multiple sclerosis. Three weeks later she was admitted to the hospital with diarrhoea and vomiting. Repeat blood tests revealed raised creatinine (528 μmol/L (normal range (NR) n=45-84 μmol/L)), urea (32.6 mmol/L (NR 2.5-7.8 mmol/L)) and creatine kinase (6792 IU/L (NR 25-200 IU/L)) levels and reduced estimated glomerular filtration rate of 7. A diagnosis of acute kidney injury secondary to rhabdomyolysis was made due to an interaction between ciclosporin and simvastatin, precipitated by the dehydration from gastroenteritis. Haemofiltration was required to stabilise her renal function and she made a complete recovery.

Tumour-bowel fistula as a possible complication of pazopanib therapy in retroperitoneal leiomyosarcoma

Pazopanib is a vascular endothelial growth factor receptor tyrosine kinase inhibitor (VEGFR TKI) that inhibits the vascular endothelial growth factor receptor A pathway and has the potential to cause ischaemic bowel changes, including perforation. Here we report a case of a 51-year-old man with large, metastatic, retroperitoneal leiomyosarcoma that developed a tumour-bowel fistula after 4 weeks of pazopanib therapy. He presented to the emergency department with sepsis and 1-week history of worsening fever, chills, nausea and diarrhoea. Abdominal CT findings of mesenteric and portal vein gas, commonly found in mesenteric ischaemia and VEGFR modulator-induced bowel toxicity, provided evidence for the causal relation. Unfortunately, the case was not amenable to surgery and patient succumbed to the illness.

Neck and supraclavicular lymphadenopathy secondary to 9-valent human papillomavirus vaccination

We present two clinical cases of lymphadenopathy after vaccination with the human papillomavirus (HPV) 9-valent vaccine: an asymptomatic 11-year-old boy with inferior cervical and supraclavicular lymphadenopathy, and a 13-year-old girl who presented with lymphadenopathy. In both cases, medical history was unremarkable and there was no recent infection, or other clinical findings. Both adolescents had received the HPV 9-valent vaccine in the previous week. In the first case, blood tests, ultrasonography and biopsy were performed, while in the second, a watchful waiting strategy was adopted. In both cases, the lymphadenopathy resolved spontaneously. The boy received the second dose of the vaccine 6 months later and lymphadenopathy reappeared. The Naranjo scale was applied, classifying the events as definite (in the case of the boy) and probable (girl) adverse drug reactions. The vaccine is safe, but recognising this minor adverse event is important to prevent unnecessary investigation and reduce patient and parental anxiety.

Amiodarone-induced diffuse alveolar haemorrhage: a rare but potentially life-threatening complication of a commonly prescribed medication

Amiodarone is an antiarrhythmic agent that is used commonly in clinical practice. It is associated with many side effects, the most common being pulmonary manifestations. Interstitial pneumonitis is one of the most common complications, however rarely amiodarone can cause diffuse alveolar haemorrhage (DAH) too. We describe the case of a 73-year-old woman who presented with shortness of breath and haemoptysis 4 days after starting amiodarone. She was diagnosed with amiodarone-induced DAH based on imaging and bronchoalveolar lavage. She was treated with intravenous and then oral steroids, and amiodarone was discontinued. The patient made a significant clinical and radiological recovery. She was discharged 10 days after her presentation. This case highlights a rare but potentially life-threatening complication of a commonly used medication.

Antifungals in a case of basidiobolomycosis: role and limitations

A 10-year-old Saudi boy was diagnosed to have basidiobolomycosis after a stormy course of his ailment. Therapy was initiated with intravenous antifungal, voriconazole, which was well tolerated for 6 weeks except for local excoriation at the site of ileostomy. He developed drug-induced hepatitis on oral voriconazole, therefore, switched to oral itraconazole following which he experienced severe chest pain. Alternatively, co-trimoxazole (bactrim) an antibacterial with antifungal activity was prescribed but he had the intolerance to it as well. Unfortunately, posaconazole as an alternative antifungal was not available in our centre. We report here a Saudi boy who developed an intolerance to most common antifungals used clinically 6 weeks after the therapy was initiated.

Delayed onset bioabsorbable screw reaction, intact screw extrusion and Pseudomonas aeruginosa tibial tunnel osteomyelitis years after arthroscopic anterior cruciate ligament reconstruction using hamstring graft

Postoperative reaction and infection after anterior cruciate ligament (ACL) reconstruction is a rare complication. We report two cases of bioabsorbable screw extrusion and Pseudomonas aeruginosa tibial tunnel infection in 17/18-year-old men, 2 and 4 years after ACL reconstruction, respectively. They underwent tibial tunnel debridement, removal of the still intact poly-L-D-lactic acid bioabsorbable screw and subsequent wound closure. Physical examination findings confirmed patency of the hamstring graft. Culture guided antibiotics were completed, and wounds healed unremarkably. Both returned to previous level of activity. Successful treatment is achieved through a logical sequence of management, as well as a multidisciplinary approach to prevent unnecessary secondary procedures and morbidity.

An unusual presentation of ACE inhibitor-induced visceral angioedema

ACE inhibitors (ACEi) are common anti-hypertensive drugs that can cause angioedema. Though classic, or facial angioedema is rare, visceral angioedema is even less common. When angioedema occurs, it typically presents early, within 30 days of initiating therapy. Visceral angioedema most commonly presents with nausea, emesis, abdominal pain and diarrhoea, and thus is often mistaken for an episode of gastroenteritis. When a CT scan is obtained, it typically shows characteristic findings, including ascetic fluid, mild mesenteric oedema and thickening of the small bowel. In this case report, we present a patient who did not experience her first episode of visceral angioedema until after she had been on ACEi therapy for 5-7 years. In addition, she experienced recurrent episodes of visceral angioedema that were separated by approximately 4 years at a time. Both of these features make for a particularly unique presentation.

Optic shrinkage and retraction in opacified hydrophilic acrylic intraocular lens: an anterior segment optical CT-based observation

Intraocular lens (IOL) opacification is a rare phenomenon noted with hydrophilic acrylic IOLs. We report a case of advanced IOL opacification appreciated on anterior segment optical CT (ASOCT)as a shrunken biconcave optic retracted away from the posterior capsule (PC), unlike the other eye which had a clear biconvex IOL of similar material abutting the PC. After IOL exchange, the affected eye was noted to have more folds and Elschnig's pearls on the PC when compared with the other eye. Our case points towards rare IOL changes seen in advanced cases of opacification, their association with posterior capsular changes and the aid of ASOCT as a non-invasive tool in diagnosing them correctly.

Remission of treatment-resistant depression with tardive akathisia with electroconvulsive therapy

This report presents a case of drug-induced severe tardive akathisia developing after the combination of a selective serotonin reuptake inhibitor and an antipsychotic, in a woman with severe major depression. The trial and combination of multiple medications is common practice in treatment-resistant patients with depression. With the increase in the prevalence of treatment-resistant depression, adverse effects of medication such as tardive akathisia are becoming more common. Tardive akathisia persists even after the withdrawal of the causative agent and is very challenging to treat. The patient did not respond to any standard medications indicated for drug-induced akathisia. As a result, the patient became suicidal and extremely distressed with all treatment options exhausted. Guidelines on the management of drug-induced tardive akathisia are non-existent. This reflects the importance of this case study, which reveals the complete remission of both tardive akathisia and all the patient’s depressive symptoms after electroconvulsive therapy. This report provides evidence of an established treatment intervention used in a new situation.

Vancomycin induced DRESS syndrome (drug reaction with eosinophilia and systemic symptoms) in a patient with tricuspid endocarditis

A 57-year-old man presented for an elective pacemaker upgrade, complicated by the discovery of device infection. He had a background of complex congenital heart disease, including replacement of heart valves, and was treated for presumed infective endocarditis that was later confirmed by echocardiography. Antibiotic treatment, with intravenous vancomycin, was given as per the tissue sample sensitivities. On day 24 of treatment he deteriorated clinically, with the evolution of recurrent fever, epigastric pain, diarrhoea, widespread pruritic rash, lymphadenopathy and severe hypoxia over the subsequent 7-10 days. Blood tests revealed development of a marked eosinophilia, transaminitis and rising inflammatory markers. Further radiological imaging was non-diagnostic. On the basis of these clinical and biochemical features a diagnosis of drug reaction with eosinophilia and systemic symptoms syndrome was made. This led to the cessation of vancomycin, the offending agent and the referral for specialist immunology advice. He was subsequently treated with oral prednisolone and made a full recovery.

Imatinib-induced pericardial effusion in a child

A 12-year-old boy presented with central chest pain, shortness of breath and type 1 respiratory failure. He had a background of graft versus host disease (GvHD), which was currently managed with imatinib therapy. A focused bedside ultrasound scan was performed revealing a large pericardial effusion. The child was referred to a tertiary paediatric cardiology centre where he underwent emergency pericardiocentesis, draining a total of 800 mL of pericardial fluid. Fluid analysis excluded infection, and with no other concerns for a GvHD flare the diagnosis of an imatinib-induced pericardial effusion was made. On terminating the therapy, the pericardial collection did not reaccumulate. Tyrosine kinase inhibitor-induced pericardial and/or pleural effusion should be considered as a differential diagnosis in paediatric patients on this therapy presenting in a similar manner.

DPP-4 inhibitor (sitagliptin)-induced seronegative rheumatoid arthritis

Sitagliptin is a dipeptidyl peptidase-4 inhibitor commonly used in the treatment of type 2 diabetes mellitus for glycaemic control. Concerns have arisen regarding adverse events caused by this drug, particularly concerning arthralgias. Here, we report on a 56-year-old man being treated with sitagliptin who developed inflammatory arthritis after taking the drug for 6 months. The patient presented with pain, swelling and erythema in multiple joints and was eventually diagnosed with seronegative rheumatoid arthritis (RA) under the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria. His symptoms continued for several months after stopping sitagliptin and eventually went into remission after a tapered course of steroids, hydroxychloroquine and methotrexate. Furthermore, the patient is HLA-DRB3 positive, a genetic marker that is still being investigated for its role in the pathogenesis of RA and that may have been a predisposing factor in the development of this patient's inflammatory arthropathy.

Herpes simplex virus encephalitis in a patient receiving ustekinumab associated with extensive cerebral oedema and brainshift successfully treated by immunosuppression with dexamethasone

Herpes simplex virus (HSV) encephalitis affects 2-4 people per million/year. Immunocompomised patients can have atypical presentations of HSV encephalitis, including a lack of cerebrospinal fluid (CSF) pleocytosis. We present the case of a patient who was receiving ustekinumab therapy for psoriasis which inhibits interleukin (IL)-12 and IL-23 signalling pathways. The initial presentation was suggestive of encephalitis, but he was discharged prior to the reporting of HSV positivity due to the lack of CSF pleocytosis. On representation, he had worsening symptoms and imaging showed midline shift, indicating cerebral oedema despite the immunosupressant effects of ustekinumab. He required intensive care unit support and treatment with high dose aciclovir and dexamethasone; after a month of treatment he made a good recovery. This case is the first to report a link between ustekinumab and HSV encephalitis, and also emphasises that imunocompromised patients can lack CSF pleocytosis and develop significant cerebral oedema which responds to immune suppression.

A rare case of Miller Fisher variant of Guillain-Barr Syndrome (GBS) induced by a checkpoint inhibitor

With the recent development of novel, more potent cancer treatment, in particular, immune 'checkpoint inhibitors', cases of neurological immune-related adverse events are on the rise. Although rare, this includes Guillain-Barré Syndrome (GBS). We present the case of a 68-year-old male who was admitted with sudden onset of worsening neurological symptoms following immunotherapy treatment. These symptoms progressed quickly to respiratory failure requiring intubation and admission to the intensive care unit. He was thoroughly investigated and is believed to have an axonal neuropathy in the form of Miller Fisher Syndrome (MFS) variant of GBS, secondary to immunotherapy treatment. He was initially treated with intravenous immunoglobulin, and later, perhaps more effectively, with high dose steroids which significantly improved his symptoms. This case of checkpoint inhibitor-induced MFS is one of few in the literature and is an important reminder of the potential for new immunotherapeutic agents to cause significant neurotoxic effects. These should be promptly and thoroughly investigated, in particular, as the management of these patients can differ from standard treatments used in these conditions.

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.

Myoclonic status epilepticus induced by cefepime overdose requiring haemodialysis

We report a case of cefepime neurotoxicity characterised by myoclonic status epilepticus with coma, in a context of acute renal failure and requiring one discontinuous conventional haemodialysis. Cefepime is a fourth-generation broad-spectrum cephalosporin mainly used to treat hospital-acquired Gram-negative infections. Acute neurotoxicity is an increasingly reported adverse effect which occurs predominantly in patients with renal impairment. Renal replacement therapy has been proposed to treat this condition.

Skin staining following intravenous iron infusion

This report describes the case of a 36-year-old woman, gravida 3, para 2, at 11 weeks' gestation, who received a ferric carboxymaltose infusion for iron deficiency anaemia after medical management of a miscarriage. The following morning, light brown skin staining was noted at the infusion site, and the staining was present 2 months later at follow-up. Skin staining following intravenous iron infusion is a rare but important side effect. The skin staining is potentially permanent but may fade in time. Such an adverse effect may have cosmetic consequences for the patient.

Homeopathy-medicine induced severe alcoholic hepatitis

We present a teetotaler with compensated non-alcoholic fatty-liver-disease related cirrhosis who presented with acute worsening of his chronic liver disease. The acute event was not discernible even after extensive work up and finally a transjugular liver biopsy revealed features suggestive of severe alcoholic hepatitis. The patient and the family denied occult alcohol use when questioned over multiple times and finally, the culprit 'alcohol' was found to be the homoeopathy medicines that the patient was consuming over a month for treatment of Gilbert's syndrome. We retrieved and tested the homoeopathy drug for alcohol content and found an alarming 18% ethanol in the same, confirming our diagnosis.

Hydroxychloroquine-induced podocytopathy mimicking Fabry disease

Hydroxychloroquine (HCQ) is largely prescribed as an immunomodulator to prevent systemic diseases flares in patients with systemic lupus erythematous, rheumatoid arthritis, Sjogren's disease. Among reported side effects, HCQ can accumulate in lysosomes and induced phospholipidosis. Here, we report an HCQ-induced podocytopathy mimicking Fabry disease (FD). They share the same histological lesions: cytoplasmic vacuolisation of the podocytes and zebra bodies on light and electronic microscopy. FD has been ruled out by measuring enzymatic activity and genetic test. The persistence of proteinuria after immunological remission of a systemic disease treated with HCQ could suggest this HCQ-induced podocytopathy.

Anti-HMGCR myopathy presenting with acute systolic heart failure

Necrotising autoimmune myopathy (NAM) is an immune-mediated myopathy that may be associated with statin use, malignancy or an autoimmune connective tissue disease, but it can also be idiopathic. Anti-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) myopathy is an extremely rare side effect of statin use, occurring in approximately 2-3 out of every 100 000 patients who use statins. Patients typically present with subacute proximal muscle weakness and creatine kinase levels >10 times the upper limit of normal. The diagnosis is suggested by muscle biopsy showing necrotic fibres with minimal inflammation along with positive anti-HMGCR antibodies. Treatment nearly always requires multiple immunosuppressive agents, the earlier use of which is associated with improved outcomes. Reports of statin-induced NAM leading to heart failure are limited. We present the case of a 69-year-old woman with statin-induced NAM who presented with acute systolic heart failure. Early initiation of high-dose corticosteroids and IVIG resulted in significant improvement in her symptoms.

Posaconazole in the treatment of refractory Purpureocillium lilacinum (former Paecilomyces lilacinus) keratitis: the salvation when nothing works

We report a case of a 41-year-old woman, wearer of contact lenses who was presented to the emergency room with a 2-month history of pain and red eye. She presented with a severe keratitis refractory to quinolones, fortified antibiotics and clotrimazole. Due to the risk of perforation, a tectonic penetrating keratoplasty (PK) was performed. Clinical signs of keratitis recurrence were observed and cultures were positive for Purpureocillium lilacinum (former Paecilomyces lilacinus) The patient did not improve on topical amphotericin B and intracameral voriconazole. Worsening of clinical condition required a new PK. Oral posaconazole was initiated postoperatively and suspended at the fourth postoperative month. The cornea remains clear until the last follow-up visit, 12 months after the second graft. To our knowledge, this is the second case report that documents the effectiveness of oral posaconazole in a refractory P. lilacinus keratitis, resistant to other second-generation triazoles and conventional antifungals.

Acute ST-elevation myocardial infarction due to in-stent thrombosis after administering tranexamic acid in a high cardiac risk patient

Tranexamic acid (TXA) is an antifibrinolytic which minimises bleeding and transfusions, with thrombotic risk. Our patient had known coronary artery disease with post-TXA acute ST-elevation myocardial infarction (STEMI) due to in-stent thrombosis. He had five drug-eluting stents (DES): two overlapping DES in mid-LAD (3 years ago), and two overlapping DES in distal right coronary artery and one DES in obtuse-marginal (1.5 years ago). After TXA, both overlapping stent locations thrombosed. Of nine reports of post-TXA acute MI, only one had complex stent anatomy (bifurcation stent to left circumflex/first obtuse-marginal) with other single stents, and only the complex stent thrombosed. Post-TXA MI was more often STEMI caused by arterial thrombosis, rather than non-STEMI caused by blood loss, hypotension or demand ischaemia. Overlapping and bifurcation stents thrombosed; single stents remained patent. In conclusion, overlapping stents, bifurcation stents, excessive stent length and previous in-stent restenosis/thrombosis may increase thrombotic risk. TXA should be administered cautiously with complex stent anatomy.

Spontaneous psoas haematoma secondary to antiplatelet therapy: a rare cause of atraumatic hip pain

A 92-year-old woman with previous total hip replacement presented with sudden onset of atraumatic hip pain and inability to weight bear. In the absence of radiographic signs of fracture, loosening or biochemical evidence of infection a CT scan of the pelvis and hips was performed, which showed psoas thickening. MRI identified two separate collections related to the psoas and greater trochanteric regions. Ultrasound-guided aspiration was performed to rule out infection and demonstrated a haematoma. In contrast to previously reported cases caused by anticoagulant therapy or inherited coagulopathy, this case was secondary to single antiplatelet agent treatment alone. In the increasingly co-morbid ageing population with associated polypharmacy, aspirin is a common primary and secondary prevention treatment. In patients with atraumatic hip pain, spontaneous psoas haematoma due to antiplatelet therapy should be considered and investigated appropriately.

Insidious-onset, non-wheezing carteolol-induced asthma in an atopic patient without asthma history

Carteolol, a non-selective beta-antagonist with a potential risk of severe bronchial constriction in patients with asthma, is one of the most commonly prescribed medication for managing ocular pressure in glaucoma. We present a case of a 24-year-old woman with a history of atopy but no known asthma who presented an insidious onset of clinical manifestations compatible with drug-induced asthma after the initiation of carteolol for ocular hypertension control. The patient developed progressive chest tightness and dyspnoea for 2 months before the pulmonary function test revealed a positive bronchoprovocation response. She reported significant improvement of respiratory symptoms within 2 weeks after the discontinuation of carteolol, and a negative provocation response was later confirmed by repeat pulmonary function test. In conclusion, eye drops with non-selective beta-antagonising effect can induce asthmatic symptoms in patients without a previous diagnosis of asthma and should be administered with caution in patients with associated risk factors.

Adalimumab-induced IgA nephropathy

Immunoglobulin A nephropathy (IgAN) is the most commonly diagnosed glomerulonephritis worldwide. It is usually idiopathic and may be associated with many other diseases. Recently, biological agents including tumour necrosis factor alpha (TNFα) inhibitors have been identified as a potential cause for IgAN. We report the case of a 39-year-old woman who presented with renal dysfunction and visible haematuria. She had a background of Crohn's disease (CD) and had been on adalimumab for 4 years following a right hemicolectomy. Subsequently, she underwent a renal biopsy that demonstrated IgAN and adalimumab was ceased. Following a flare in her CD, she was commenced on infliximab, which led to remission of the IgAN and CD. This is the first case to demonstrate the occurrence of IgAN as a complication of a TNFα inhibitor (adalimumab) that remained in remission despite the commencement of a second TNFα inhibitor (infliximab).

Acute liver injury induced by red yeast rice supplement

A 64-year-old woman previously taking no medications presented with acute hepatitis 6 weeks after starting a red yeast rice supplement to decrease her cholesterol. Red yeast rice is commonly used for hyperlipidaemia as an alternative to statins as it contains monacolin K, the same active chemical in lovastatin. Infectious, toxic and autoimmune causes for injury were ruled out, and liver biopsy was consistent with drug induced liver injury. Red yeast rice appeared to be the cause of her hepatotoxicity. After stopping the supplement and initiating treatment with intravenous methylprednisolone, liver enzymes decreased towards baseline.

Nivolumab-induced hypophysitis leading to hypopituitarism and secondary empty sella syndrome in a patient with non-small cell lung cancer

We describe the clinical course of a 64-year-old woman with stage IVa lung adenocarcinoma who presented with over 1 month of fatigue, unintentional weight loss and emesis. She initiated treatment with nivolumab immunotherapy 1 year prior and had been tolerating the treatment well. A comprehensive workup revealed multiple endocrinological abnormalities consistent with hypophysitis leading to hypopituitarism in the form of central adrenal insufficiency and hypogonadism as well as a partially empty sella on imaging. This case demonstrates that while receiving novel forms of treatment such as immunotherapy, patients should be monitored closely for a wide range of adverse effects.