Documented Case Reports Research Articles

Serotonin Toxicity as a Consequence of Linezolid Use in Revision Hip Arthroplasty

Linezolid is the first in a new group of antibiotics called oxazolidinones. As a potent antimicrobial, it has activity against methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, penicillin-resistant Streptococcus pneumoniae, and macrolide-resistant streptococci. There are several documented case reports of serotonin toxicity when used with selective serotonin reuptake inhibitors. The symptoms of serotonin syndrome are alteration of mental state, autonomic dysfunction, and neuromuscular disorders. This article presents a case of an interaction of the serotonin reuptake inhibitor venlafaxine and linezolid and the possible diagnostic problems that can occur. A 58-year-old woman presented with signs of systemic infection. Her medical history included bladder resection for transitional cell carcinoma, bilateral total hip arthroplasty (THA), and depression, for which she was on venlafaxine. Serological and imaging investigations revealed MRSA infection of the bilateral THA. The patient was started on vancomycin and rifampicin intravenously. As intravenous access was becoming problematic and long-term antibiotics were needed, treatment was changed to oral linezolid and oral rifampicin. Four days after the commencement of linezolid, the patient was acutely disorientated with generalized cerebellar signs and no autonomic dysfunction. A computed tomography scan of the head and lumbar puncture revealed no abnormal findings. A diagnosis of serotonin toxicity was made. The patient recovered when linezolid and venlafaxine were discontinued and supportive measures were provided. Linezolid is a popular choice of antibiotic, especially for the treatment of orthopedic-related MRSA infections. Patients who commonly require linezolid as an antimicrobial are those with complex infections where other antibiotic treatment has failed. It is therefore important to be vigilant with linezolid use. Physicians should be aware of the nonspecific presentation of serotonin symptoms and the treatment.

Interações entre fármacos e medicamentos fitoterápicos à base de ginkgo ou ginseng

Os medicamentos fitoterápicos são amplamente utilizados, principalmente, pelos portadores de doenças crônicas e em associações medicamentosas com diversos fármacos. As possíveis interações entre eles estão sendo muito estudadas, pois podem alterar os perfis de eficácia e segurança de muitos fármacos. Nesta revisão, as informações foram localizadas, avaliadas e sistematizadas e contêm as principais interações entre fármacos e medicamentos fitoterápicos elaborados com ginkgo ou ginseng. Verificou-se que os medicamentos fitoterápicos elaborados com tais plantas podem interferir na farmacocinética e/ou farmacodinâmica de diversos fármacos, podendo provocar conseqüências graves aos pacientes. O ginkgo pode interferir com anticoagulantes orais, antiplaquetários e com fármacos metabolizados pelo sistema P450-CYP3A4. O ginseng pode interagir com antidepressivos inibidores da monoamino oxidase, anticoagulantes orais, anti-hipertensivos, e contraceptivos à base de estrogênios. Além disso, não é recomendada a administração concomitante de ginkgo ou ginseng com antineoplásicos. Nesse sentido, o uso concomitante de medicamentos fitoterápicos à base de ginkgo ou ginseng com outros fármacos deve ser adequadamente monitorado.

Drug-Induced Pancreatitis

Drugs are a relatively rare cause of acute pancreatitis, with an estimated incidence of 0.1-2%. Many drugs have been suspected of causing pancreatitis, but the true incidence is not known as the evidence is derived mainly from random case reports. Case reports with the strongest evidence are those that clearly diagnose pancreatitis and exclude common aetiologies, provide the dose and time interval between the start of treatment with the suspected drug and the development of pancreatitis, document response to withdrawal of the drug, and demonstrate recurrent pancreatitis upon rechallenge with the drug. Few data exist on the mechanisms of drug-induced pancreatitis. Certain subpopulations such as children, women, the elderly and patients with advanced HIV infection or inflammatory bowel disease may be at higher risk. The diagnosis of drug-induced pancreatitis is often challenging because there are no unique clinical characteristics to distinguish drugs from other causes of pancreatitis. The majority of cases are mild, but severe and even fatal cases may occur, thus making identification of the offending agent critical. Management of drug-induced acute pancreatitis requires withdrawal of the offending agent and supportive care. Prevention of drug-induced pancreatitis requires an up-to-date knowledge of drugs that have the strongest evidence linking their use to the development of pancreatitis as well as the proposed mechanisms through which they may cause the reaction. In this paper, the epidemiology, diagnosis, management and prevention of drug-induced pancreatitis is reviewed. Drugs and classes of drugs strongly implicated as causing acute pancreatitis, based on well documented case reports, are discussed in detail.

Primitive Neuroectodermal Tumor Arising in a Testicular Teratoma with Retroperitoneal Metastasis: Report of an Interesting Case with Review of Literature

Teratomas with malignant transformation occur in approximately 3 to 6% of patients with metastatic germ cell tumors treated with platinum-based chemotherapy. The histology of the nongerm cell (somatic) malignant elements most commonly includes carcinoma and various types of sarcomas; however, so far as the primitive neuroectodermal tumors (PNETs) are concerned the experience is quite limited. There are only seven documented case reports and occasional series of PNET in association with testicular teratoma either in the primary site or in the metastatic location. We report a relatively unusual case of PNET arising in a malignant mixed germ cell tumor in a 35-year-old man.

Bradyarrhythmias in pregnancy: a case report and review of management

We present a case of unpaced pre-existing congenital heart block in pregnancy, diagnosed for the first time in labour. Our patient was asymptomatic and was managed conservatively with temporary pacing equipment on standby. She had a post-partum cardiology follow-up and was paced in the puerperium. We discuss the aetiopathogenesis and the variable presentation patterns of bradyarrhythmia in pregnancy and the multidisciplinary approach to their management. Our recommendations combine the Advanced Life Support algorithm for treatment of bradycardia and the successful management strategies of several documented case reports in the literature.

Evidence-based drug–herbal interactions

Due to the growing use of herbals and other dietary supplements healthcare providers and consumers need to know whether problems might arise from using these preparations in combination with conventional drugs. However, the evidence of interactions between natural products and drugs is based on known or suspected pharmacologic activity, data derived from in vitro or animal studies, or isolated case reports that frequently lack pertinent information. The usefulness of such information is questionable. More recently an increasing number of documented case reports, in vivo studies, and clinical trials have evaluated herbal–drug interactions. Results have sometimes been contradictory and more research is needed. Since there is a lack of rigorous studies that can establish the clinical significance of herb–drug interactions, an evidence-based evaluation of the current literature concerning commonly used herbal–drug interactions, as well as other dietary supplements, was conducted.

Renal parenchymal carcinoma in children.

A series of 14 cases of renal parenchymal carcinoma in patients under 20 years of age is presented and reviewed with the best documented case reports from the literature. Unlike its adult counterpart the tumour has an equal sex ratio and minor trauma frequently precipitates presentation, otherwise its behaviour is similar. The treatment of choice is nephrectomy but, unlike adults, there is evidence to support the value of adjunctive radiotherapy and chemotherapy in the treatment of local spread. Prognosis is particularly worsened by cellular granularity, and vascular or direct extrarenal spread. The 5 year survival rate is 52 per cent.

Double‐chambered right ventricle: Magnetic resonance imaging findings

Primary double-chambered right ventricle is an uncommon congenital anomaly that presents with right ventricular outflow tract obstruction in childhood or adolescence. A search of the literature revealed only a few documented case reports with MRI findings. We present a case with mixed lesions, and with anomalous muscle bundles located both in the middle portion of the right ventricular sinus and at the subinfundibular level.

Catatonia in Juvenile Corrections

Back to table of contents Previous article Next article Letter to the EditorFull AccessCatatonia in Juvenile CorrectionsJULIE A. NIEDERMIER, M.D., JULIE A. NIEDERMIERSearch for more papers by this author, M.D., Columbus, OhioPublished Online:1 Nov 2004AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: The following are reports on three male youths who were diagnosed with catatonia while residing in an intensive mental health unit within a juvenile correctional facility.Abe, a 14-year-old African American youth who was diagnosed previously with both schizophrenia and bipolar disorder with psychotic features, was admitted because of paranoid delusions that his food was being poisoned and subsequent inadequate food intake, with a 10-lb weight loss over a 4-week interval. He demonstrated repeated inappropriate touching and maintenance of assumed positions for up to 10 minutes at a time. He was extremely combative at times but immobile at others. He exhibited mutism, stereotypy, mannerisms, negativism, and staring. His Bush-Francis Catatonia Rating Scale score was 26. (1) Abe was treated with lorazepam, 2 mg/day, and his catatonic signs and food intake improved dramatically over the following 5 days. He was treated with quetiapine and lithium for the next 18 months, with partial remission of his mood and psychotic symptoms until he became noncompliant. Abe’s catatonic signs reemerged, and he again responded favorably to lorazepam, 2 mg/day. For the past year, he has been receiving treatment with clozapine and lithium and remains in full remission of catatonic, mood, and psychotic symptoms, with dramatic improvement in social, interpersonal, and educational functioning.Mr. B, an 18-year-old Caucasian man with a history of cannabis abuse and declining social, vocational, and interpersonal involvement (but no previous diagnoses of mood or psychotic disorder), was admitted because he was talking to himself, had lack of motivation, and was laughing inappropriately. He exhibited profound mutism, intermittent excitement, posturing, staring, mannerisms, stereotypy, perseveration, autonomic abnormality (elevated blood pressure), automatic obedience, and impulsivity. His Bush-Francis Catatonia Rating Scale score was 24. His catatonic signs responded well to lorazepam, 3 mg/day. Manic symptoms subsequently emerged, and Mr. B was diagnosed and treated for bipolar disorder.Carl, a 17-year-old Caucasian youth who was previously diagnosed with schizoaffective disorder, was admitted because of declining self-care, response to internal stimuli, and bizarre delusions. He displayed facial grimacing that resolved completely when risperidone, 5 mg/day, was discontinued. His Bush-Francis Catatonia Rating Scale score was 18, and his catatonic signs included immobility, mutism, excitement, posturing, staring, mannerisms, echolalia, stereotypy, negativism, gegenhalten, ambitendency, impulsivity, and combativeness. These signs resolved with lorazepam treatment, 3 mg/day.All youths had negative serum toxicology screens upon admission to the facility and, in the case of Mr. B, for 6 months before admission, as verified through court-ordered monitoring. The youths received medical and neurological evaluations, including hematological, metabolic, toxicological, and CSF analysis, EEGs, and neuroimaging. All results were normal or lacked positive findings. Prenatal and developmental histories were unremarkable, although Abe and Carl had extensive family histories of mental illness.There have been several case series and reports of catatonia occurring in the child and adolescent population (2). Although substantial psychiatric morbidity has been identified among youths in the juvenile justice system (3), I am unaware of previous case reports of catatonia occurring among youths detained within the juvenile justice system. Presumably, the etiology and risk factors leading to catatonia in adolescents and young adults in juvenile justice and community settings is similar, regardless of criminal history. However, the identification of this syndrome in male juvenile offenders is especially important, given the paucity of resources for adolescents and the increasing recognition of the prevalence and severity of mental illnesses among juvenile offenders (4). Incarcerated juveniles may exhibit unusual behavioral phenomena, making detection of psychiatric disorders in need of treatment extremely difficult (5).Considerable functional improvement was evident in all three cases after treatment of catatonia, similar to documented case reports. Also, more youths are entering the criminal justice system than ever before. With more diverse clinical treatment settings and declining resources, greater awareness of the catatonia syndrome, with its well-defined features and response to treatment (6), may aid in its recognition and management.

Nontumoral dermatologic problems after liver transplantation.

The skin, easily accessible for medical examination, is affected in many ways by liver transplantation. Mucocutaneous manifestations of advanced liver disease and dermatologic conditions associated with specific hepatic diagnoses generally improve after liver transplantation. Vasculitic lesions due to cryoglobulinemia associated with hepatitis C, and photosensitivity due to porphyria are occasional exceptions. Dermatologic diseases complicating the posttransplantation course can be challenging. Their presentation is sometimes unusual and their course severe. Infections with rare organisms alone or in combination may occur. Our intent is to provide an overview of the current knowledge regarding nontumoral dermatologic problems associated with liver transplantation by summarizing the available information from all documented case reports.

Mucinous cystadenoma of the pancreas 17 years after excision of gallbladder because of a choledochal cyst

A 56-year-old woman who had undergone excision of the gallbladder because of a choledochal cyst had a tumorous lesion of the pancreas identified by upper abdominal ultrasonography, but an operation was not carried out, because there was no apparent increase in the cystic mass and no elevation of serum tumor markers. In October 2001, she was admitted to our hospital to check for malignancy because of elevated levels of the tumor marker Dupan-2. Abdominal enhanced computed tomography and upper abdominal ultrasonography revealed a large multilocular cystic mass in the body to tail of the pancreas. Endoscopic retrograde cholangiopancreatography showed elongation of the common duct that communicates with the common bile duct and the main pancreatic duct, indicating an anomalous arrangement of the biliary and pancreatic duct system. No apparent communications between the cystic mass and the main pancreatic duct were observed. In January 2002, the patient underwent a spleen-preserving distal pancreatectomy, and histopathological and immunohistochemical examinations led to the diagnosis of pancreatic mucinous cystadenoma with ovarian-like stroma. The mucinous cystadenoma was detected 17 years after the operation for the choledochal cyst. To the best of our knowledge, no documented case reports of mucinous cystadenoma of the pancreas associated with a choledocal cyst have been reported to date. We present here the first case report of pancreatic mucinous cystadenoma occurring in the body to tail of the pancreas, associated with a choledocal cyst.

Watermelon stomach following and preceding systemic sclerosis

Objectives: To report two patients with watermelon stomach associated with systemic sclerosis (SSc) and review the literature on that subject. Methods: We describe the clinical presentation, course and outcome of our two patients and reviewed the medical literature registered in the MedLine PubMed database from 1966 to 1999 by using the key words watermelon stomach, gastric antral vascular ectasia, systemic sclerosis, scleroderma.Results: The two patients presented with microcytic hypochromic anemia. Esophagogastroscopy showed multiple linear vascular malformations in the antrum compatible with watermelon stomach. They responded to Nd-Yag laser therapy with resolution of the lesions and improvement of the anemia. Patient 1 had a history of diffuse SSc while patient 2 developed limited SSc 2 years after the diagnosis of watermelon stomach. A literature review disclosed 16 documented case reports of watermelon stomach associated with SSc, 14 of whom were women. In most cases, watermelon stomach occurred in patients with established SSc but in some it antedated it by several years. In many cases, other autoimmune syndromes such as hypothyroidism, primary biliary cirrhosis, and Sjögren's syndrome were present. The presenting symptom was iron deficiency anemia, which in 11 cases was severe enough to require blood transfusions. Nine patients were successfully treated with several transendoscopic treatments, four required surgical intervention, and in three treatment was not specified. Conclusion: Although watermelon stomach is a rare syndrome, it is recognized as a cause of persistent bleeding in patients with SSc. Awareness of this condition may increase its recognition and treatment. Semin Arthritis Rheum 30:127-131. Copyright © 2000 by W.B. Saunders Company

Refining the MAOI Diet

Continuous refinement of the monoamine oxidase inhibitor (MAOI) diet has resulted in much reduced and simplified recommendations that attempt to balance safety and practicality. In the spirit of evidence-based practice, dietary restrictions should be based on carefully documented case reports and valid tyramine analyses. Residual concerns have focused on combination foods such as pizza and a variety of soy products. We determined the tyramine content of pizzas and a variety of soy products in order to refine dietary recommendations for use with MAOIs. High-pressure liquid chromatography analysis of tyramine content was performed on a variety of pizzas, soy sauces, and other soybean products. A tyramine level of 6 mg or less was considered safe. No significant tyramine levels were found in any of the pizzas, including those with double pepperoni and double cheese. Marked variability was found in soy products, including clinically significant tyramine levels in tofu when stored for a week and high tyramine content in one of the soy sauces. Pizzas from large chain commercial outlets are safe for consumption with MAOIs. However, caution must be exercised if ordering pizzas from smaller outlets or gourmet pizzas known to contain aged cheeses. All soybean products should be avoided, especially soy sauce and tofu. Individualized counseling and continuous surveillance of compliance are still essential.

VAGINAL ECTOPIC URETER WITH GARTNER'S DUCT CYST

In ureteral duplication anomalies a distal lower ectopic ureter usually will not require removal after heminephrectomy. We recently cared for a woman presenting with a purulent vaginal discharge. Retained secretions in an ectopic ureter draining into a Gartner’s duct cyst necessitated distal ureterectomy. The Gartner’s duct cyst was left in place in the vagina. CASE REPORT A 24-year-old woman presented with recurrent urinary tract infections and persistent purulent vaginal discharge. Evaluation of incontinence at age 5 years had revealed a duplicated collecting system on the right side, and right upper pole heminephrectomy was performed. The location of the upper pole ureteral orifice was never identified. At age 19 years further evaluation for the same symptoms revealed a ureteral orifice adjacent to the urethral meatus at the introitus. Left upper pole heminephrectomy was performed with resolution of incontinence. Excretory urography was performed for the recurrent symptoms and confirmed the bilateral heminephrectomies. Cystoscopy revealed normally placed ureteral orifices in the bladder. The left ectopic ureteral orifice could not be seen at the introitus or in the urethra. On vaginal examination a purulent discharge was seen coming from the area of a right Gartner’s duct cyst (fig. 1). Abdominal computerized tomography revealed a tubular, fluid filled structure running adjacent to the right ureter (fig. 2). Distal ureterectomy through a suprapubic approach was performed without removal of the vaginal component. The patient remains well 6 months following distal ureterectomy. The Gartner’s duct cyst remains palpable but no further treatment has been necessary. duplicated collecting system on the left side with an ectopic FIG, 1, speculum examination reveals Gartner,s duct cyst (large lateral to cervix DISCUSSION Embryologically, the ureteral bud arises from the mesonephric duct, separates from its origin and inserts into the urogenital sinus.’ The distal remnant of the mesonephric duct becomes the Gartner’s duct, which runs from the hymen to the uterine adnexae along the lateral vaginal wall. Failure of the ureteral bud to separate from the mesonephric duct leads to ureteral termination in the Gartner’s duct or Gartner’s duct cyst. Vaginoscopy or speculum examination may reveal the Gartner’s duct cyst lateral to the cervuf as Seen in this patient. While the urological literature descnbes ectopic ureteral entry into a Gartner’s duct cyst, documented case reports are rare due to the infrequency with which the distal ureter needs to be removed.z.3 Whether the Gartner’s duct cyst itself needs to be removed and with what morbidity are not well delineated in the urological literature. we elected not to remove the cyst to avoid entering the vawa but we would perform marsupialization of the cyst If the Patient were to become symptomatic.

Severe rhabdomyolysis following a viral illness: A case report and review of the literature

Rhabdomyolysis is a syndrome often associated with alcohol and drug abuse. It may also be seen following viral infections, but is a complication not often considered. We report a case of severe rhabdomyolysis following an influenza-like illness. Despite the extreme elevation of creatinine phosphokinase, 230,600 IU/L, this patient did not develop acute renal failure in contrast to most of the previously documented case reports of rhabdomyolysis associated with influenza virus. This case report illustrates the difficulty in predicting which patients are at risk for developing acute renal failure and emphasizes the need for aggressive treatment of any patient, suspected of having rhabdomyolysis.

Use of Intravenous Immunoglobulins in Haematological Disorders

With many controlled clinical trials and well documented case reports, therapy with intravenous immunoglobulins (IVIg) is now used as a major or adjuvant therapeutic modality in a great number of haematological diseases. Immune-mediated peripheral cytopenias with severe clinical complications may require instantaneous improvement and, generally, the response to high doses of IVIg is more rapid than that to corticosteroids. As a rule, the acute forms of idiopathic thrombocytopenic purpura (ITP) respond more consistently than the chronic forms, in which the response to IVIg is more transient. The immunopathogenic mechanisms leading to cytopenia crucially influence the response; for example, ITP due to HIV infection is more resistant to IVIg than acute ITP due to other viral infections or the purely idiopathic forms.

Adverse drug interactions with nonsteroidal anti-inflammatory drugs (NSAIDs). Recognition, management and avoidance.

The prevalence and incidence of adverse drug interactions involving nonsteroidal anti-inflammatory drugs (NSAIDs) remains unknown. To identify those proposed drug interactions of greatest clinical significance, it is appropriate to focus on interactions between commonly used and/or commonly coprescribed drugs, interactions for which there are numerous well documented case reports in reputable journals, interactions validated by well designed in vivo human studies and those affecting high-risk drugs and/or high-risk patients. While most interactions between NSAIDs and other drugs are pharmacokinetic, NSAID-related pharmacodynamic interactions may be considerably more important in the clinical context, and prescriber ignorance is likely to be a major determinant of many adverse drug interactions. Prescribing NSAIDs is relatively contraindicated for patients on oral anticoagulants due to the risk of haemorrhage, and for patients taking high-dose methotrexate due to the dangers of bone marrow toxicity, renal failure and hepatic dysfunction. Combination NSAID therapy cannot be justified as toxicity may be increased without any improvement in efficacy. Where lithium or anti-hypertensives are coprescribed with NSAIDs, close monitoring is mandatory for lithium toxicity and hypertension, respectively, and aspirin (acetylsalicylic acid) or sulindac are preferred. Phenytoin or oral hypoglycaemic agents may be administered with NSAIDs other than pyrazoles and salicylates provided that patients are monitored carefully at the initiation and cessation of NSAID treatment. Digoxin, aminoglycosides and probenecid may be coprescribed with NSAIDs, but close monitoring is required, particularly for high-risk patients such as the elderly. Indomethacin and triamterene should be avoided due to the risk of renal failure. High dose aspirin should be replaced by naproxen in patients on valproic acid (sodium valproate) and care is required when corticosteroids are administered to patients taking salicylates long term in high dosage. Interactions between NSAIDs and antacids or cholestyramine are generally avoidable. Adverse drug interactions involving NSAIDs may be limited by rational prescribing and by careful monitoring, particularly for high-risk patients, drugs and therapy periods.

IS DIET IMPORTANT IN RHEUMATOID ARTHRITIS?

There is evidence from several well documented case reports that occasional patients with rheumatoid arthritis (RA) may develop aggravation of their arthritis as a result of allergy to some ingredient in the diet. A variety of foodstuffs have been implicated including milk and milk products, corn and cereals. Total fasting results in improvement in rheumatoid arthritis, but appears to be mediated by diminution in production of chemical mediators of inflammation, rather than by elimination of a dietary allergen. There is conflicting evidence from studies using various intestinal probes that patients with rheumatoid arthritis may have a 'leaky' intestinal mucosa allowing food allergens to be more easily absorbed. Clinical therapeutic trials of exclusion diets have employed the standard strategy of the double-blind randomized method. However, this presupposes that patients entered into such a study are capable of improvement with dietary manipulation. Since this is often not the case, a more appropriate method would be to employ the 'intensive research design' also known as 'single case experiment' and 'N of 1' study. 'Masked food intolerance' is an attractive hypothesis, but extremely difficult to prove. It is doubtful whether fish oils and/or evening primrose oil will be of significant long term benefit for patients with RA. However, they do provide for the possibility that a fatty acid-like substance may be found which may be incorporated into cell membranes, thereby preventing production of mediators of inflammation, such as prostaglandin E2 and leukotriene B4.

Thrombotic Thrombocytopenic Purpura With the Acquired Immunodeficiency Syndrome: A Pathologically Documented Case Report

We report a patient with the acquired immunodeficiency syndrome (AIDS) in whom the acute onset of neurologic disorders and renal failure could be attributed to thrombotic microangiopathy. Clinical, biological, and pathological features were compatible with the diagnosis of thrombotic thrombocytopenic purpura (TTP). Such cases have been previously described, but histologically documented case reports are uncommon.

Does splenectomy predispose to meningococcal sepsis? An experimental study and clinical review

Splenectomy is a recognized factor predisposing to the late complication of serious sepsis. The meningococcus has been listed as an important organism in postsplenectomy infection. A survey of the literature, however, revealed a total of only 13 documented case reports over a 31-year period, including ten pediatric cases. No documented cases of meningococcal sepsis in children following splenectomy for trauma were found. In an experimental mouse meningococcal infection model, the intraperitoneal LD50 was similar between normal and splenectomized mice (4 X 10(8) v 4 X 10(7) cfu, respectively; P = not significant). Bacteremic patterns were similar in both groups. Uniform survival was seen in normal and splenectomized mice after various intravenous challenge doses of meningococci up to 10(6) cfu. This was associated with efficient bacterial clearance in both groups. It appears unlikely that the defect resulting from splenectomy alone is an important predisposing factor in meningococcal sepsis.