Ecchymotic Lesions Research Articles

Zanubrutinib-associated ecchymotic lesions

Zanubrutinib-associated ecchymotic lesions

Ecchymotic Skin Lesions and Hand Edema in a 10-month-old Boy.

Ecchymotic Skin Lesions and Hand Edema in a 10-month-old Boy.

Thrombotic Thrombocytopenic Purpura Complicating Secondary Sjögren's Syndrome: A Rare and Serious Association from Africa

Thrombotic Thrombocytopenic Purpura is a potentially fatal disease that can be life-threatening. The association with Sjogren’s syndrome is rare entity that deserves special attention. To this end, we report the case of a Thrombotic thrombocytopenic purpura complicating secondary Sjögren's syndrome. This is a 49-year-old patient with a history of pure nephrotic syndrome with minimal glomerular lesions (LGM), who developed Sjögren's syndrome two years later. The diagnosis of Sjögren's syndrome was retained with an etiological investigation suggesting SS secondary to SLE systemic lupus erythematosus. Six months after the diagnosis of secondary SS, the patient was admitted with headache, ecchymotic and petechial lesions on the upper limbs. The laboratory analysis revealed severe thrombocytopenia, haemolytic anemia with a schizocyte count at 6% supporting the diagnosis of thrombotic microangiopathy. The ADAMTS 13 activity assay was less than 5% and the anti-ADAMTS 13 antibody test was positive, attesting thus, the diagnosis of acquired TTP complicating SS secondary to SLE. The patient received an emergency blood transfusion of fresh frozen plasma combined with corticosteroid therapy and mycophenolate mofetil. The clinico-biological outcome, at 6 month and 1 year, was favorable with complete remission. To the best of our knowledge, this is the first case report of TTP complicating Sjögren’s syndrome in Africa. It highlights the rarity of association between autoimmune disease particulary Sjögren’s syndrome and TTP.

Forensic pilot application of rehydrating solutions on human cadaveric skin: what are the effects on hemorrhagic infiltrates?

The microscopic evaluation of hemorrhagic infiltrates is crucial in forensic diagnostics, but it proves challenging in corificated and mummified cadavers. In these cases, pre-treatment with rehydrating solutions is recommended, although their effects on the hemorrhagic infiltrate are not well understood. In this pilot study, we microscopically investigated the effect of two different rehydrating solutions-Sandison's solution and fabric softener-on well-preserved human cadaveric skin samples taken from areas affected by an ecchymotic lesion, comparing them with direct fixation in formalin. Specifically, we examined the topographic distribution of the hemorrhagic infiltrate in each layer of the skin by assigning a semi-quantitative score, conducted mutual comparisons, and performed statistical analysis. Histologically, compared to direct fixation in formalin, a slight and statistically non-significant reduction in the hemorrhagic infiltrate was observed in samples pre-treated with fabric softener. On the other hand, a more pronounced and statistically significant decrease in scores was observed in samples pre-treated with Sandison's solution. This effect is likely due to the fact that Sandison's solution, due to its components, exerts an osmotic effect, partially inducing osmotic lysis of red blood cells. Overall, extensive areas of hemorrhagic infiltrates were preserved, although to a lesser extent, while smaller foci were markedly reduced, sometimes even disappearing. The findings suggest that Sandison's solution has a detrimental effect on cutaneous hemorrhagic infiltrates, emphasizing the importance of being cautious and conducting dual sampling, using both formalin and a rehydrating solution, for forensic examination of mummified or corificated skin samples.

Pregnancy-Related Morphea: A Case Report

Background: Morphea is a skin condition marked by erythematous and hardened inflammatory lesions that can progress to atrophic and sclerotic plaques. In this case report, we present a case of a pregnant woman who showed morphea presentation. Case presentation: A 37-year-old G2P1L1 woman with a gestational age of 32 weeks and 2 days was referred to the hospital with complaints of swelling, pain, and erythema in both legs for the past week, without any obstetric complaints. Upon initial examination at the time of admission, swelling, erythema, warmth in both legs, ecchymotic lesions, and non-pitting edema were observed. Biometry and color Doppler ultrasound for evaluation of fetus growth was normal. Skin examination revealed mild erythema, warmth, and purpura and petechiae in some areas, with an orange peel appearance and firm texture on palpation. Leg lesion skin punch biopsy reported a sclerodermoid reaction pattern and findings more compatible with morphea. The patient was managed for morphea during pregnancy. However, at 38 weeks and 6 days of gestation, due to worsening symptoms and spreading stiffness to the groin area, and the need for initiating pulse corticosteroids and mycophenolate mofetil (CellCept), the patient was re-admitted for cesarean section. In the follow-up assessment, ultrasound findings were normal, IGRA, HIV antibody, HCV antibody, HBC antigen, and HBS antigen were negative, and no edema or inflammation was seen in the patient. Conclusions: In conclusion, although our patient recovered without specific treatment, predicting the recurrence or worsening of morphea in future pregnancies is challenging.

Dengue fever presenting as thrombotic thrombocytopenic purpura in adolescent girl: A case report

Thrombotic thrombocytopenic purpura (TTP) is an extremely rare presentation of dengue viral infection in children which can lead to multiple organ dysfunctions in children. It is a fatal disease and can result in mortality in children if left untreated. A 15-year-old adolescent girl presented with fever, shortness of breath, and bleeding manifestations, followed by she developed hemolytic anemia, ecchymotic skin lesions, acute kidney injury, and altered sensorium. A diagnosis of TTP due to dengue fever was made and she responded very well to a plasma transfusion therapy.

Eficacia y seguridad de un compuesto de ácidos grasos hiperoxigenados en la mejora de la microcirculación de la púrpura fulminante en pacientes pediátricos con sepsis: estudio piloto

IntroductionPurpura fulminans (PF) is a serious complication of sepsis resulting from a set of alterations characterised by the development of ecchymotic haemorrhagic lesions and skin necrosis. AimTo analyse the efficacy and safety of the topical application of HOFA compound, in the cutaneous microcirculation of PF lesions in paediatric patients affected by sepsis. Material and methodsA prospective quasi-experimental pre-test/post-test single-group conducted in a Paediatric Intensive Care Unit of a third level hospital was performed. Paediatric patients aged 0-18 years with sepsis were included. Somatic oximetry values were measured before and after application of HOFAs every 4hours over the first three days of the patients’ hospitalisation. Patient's socio-demographic and clinical variables and somatic oximetry by placing a sensor for measuring tissue perfusion on the area with PF were determined. ResultsFour patients were recruited, with a median age of 98 months. The purpuric lesions measured were mainly located on both feet and hands and, in two patients, also on the lateral malleoli and calves of both lower extremities. A total of 225 measurements were obtained, with mean pre-intervention scores of 71.17±15.65% versus 73.68±14.83% post-intervention. Statistical significance (p<0.001) was observed upon comparison of the pre- and post-intervention measurements. ConclusionsEarly and continued application of HOFAs in the management of sepsis-induced PF is an effective and safe practice in the cases analysed. In more than half of the episodes analysed, an increase in tissue microcirculation was observed after the application of HOFAs, with no adverse events.

Efficacy and safety of a hyperoxygenated fatty acid compound in improving the microcirculation of purpura fulminans in paediatric patients with sepsis: a pilot study

IntroductionPurpura fulminans (PF) is a serious complication of sepsis resulting from a set of alterations characterised by the development of ecchymotic haemorrhagic lesions and skin necrosis. AimTo analyse the efficacy and safety of the topical application of HOFA compound, in the cutaneous microcirculation of PF lesions in paediatric patients affected by sepsis. Material and methodsA prospective quasi-experimental pre-test/post-test single-group conducted in a Paediatric Intensive Care Unit of a third level hospital was performed. Paediatric patients aged 0–18 years with sepsis were included. Somatic oximetry values were measured before and after application of HOFAs every 4h over the first three days of the patients’ hospitalisation. Patient’s socio-demographic and clinical variables and somatic oximetry by placing a sensor for measuring tissue perfusion on the area with PF were determined. ResultsFour patients were recruited, with a median age of 98 months. The purpuric lesions measured were mainly located on both feet and hands and, in two patients, also on the lateral malleoli and calves of both lower extremities. A total of 225 measurements were obtained, with mean pre-intervention scores of 71.17±15.65% versus 73.68±14.83% post-intervention. Statistical significance (p<0.001) was observed upon comparison of the pre- and post-intervention measurements. ConclusionsEarly and continued application of HOFAs in the management of sepsis-induced PF is an effective and safe practice in the cases analysed. In more than half of the episodes analysed, an increase in tissue microcirculation was observed after the application of HOFAs, with no adverse events.

Severe lupus after two years of hemodialysis: It exists and can be serious

Progression of lupus nephropathy (LN) to end-stage renal disease is a serious complication and requires subsequent replacement therapy. Lupus disease activity is extinguished in chronic hemodialysis. We report the observation of a 35-year-old female patient, in conventionnel hemodialysis for two years (chronic glomerulonephritis), admitted to the emergency room for convulsions, left flaccid tenderness, cutaneous-mucosal pallor and altered general condition evolving since three days before her admission. we also observed a spontaneous ecchymotic lesions on the right arm. Echodoppler of the right upper extremity was in favor of a partially thrombosed aneurysm of the right brachial artery. The biological workup showed pancytopenia, the requested immunological workup showed a low complement C3, a positive level of anti-DNA antibodies. The patient was treated as severe lupus flare: Bolus of methylprednisolone, followed by oral administration, associated with Mycophenolate mofétil (MMF) at a dose of 1 g/d. The evolution was favorable on the clinical, biological and radiological levels.Systemic lupus erythematous (SLE) can occur even after several years of hemodialysis and sometimes in a severe form, pushing the clinician to think of this pathology in the presence of evocative signs.

A rapidly progressive painful skin lesion

A 48-year-old woman presented to our emergency department with fever and a severe painful erythematous and ecchymotic skin lesion on the third finger of the left hand, that rapidly evolved into haemorrhagic bullae with diffuse swelling and edema of all her left hand, associated with the onset of lymphangitis in her left arm and crescendo-like pain. She denied trauma or insect bite. Her past medical history was unremarkable, except for chilblains with no sequelae. She did not take any medication. She was not a smoker. Laboratory tests showed neutrophilic leucocytosis (WBC 15,000/mm3; N 14,500/mm3), a slight thrombocytopenia (139,000/mm3), elevated C-reactive protein (12 mg/dL, normal value &lt;0.5), increased procalcitonin (1.3 ng/mL, normal value &lt; 0.5) and transaminases (AST 64 U/L; ALT 70 U/L, normal value 0-31). HIV was excluded.

Skin lesions on a man's face and scalp

An 87-year-old male patient was admitted to our Clinic for diagnostic evaluation and treatment of extensive, confluent erythematous-livid areas that affected almost the entire skin of his face, scalp, and neck Figure (1). The patient also showed left eyelid ectropion and a palpable subcutaneous, painless nodule in the left mandibular region the size of an apple that bled easily. The patient had been treated for undiagnosed erythematous papules on his left cheek 2 years before and reported that his condition had dramatically worsened over the last few weeks. The patient was otherwise healthy and was only being treated for hypertension and hyperlipemia. Multiple computed tomography (CT) scans were performed which showed an extensive disease affecting the skin and subcutaneous tissue of almost the entire face, scalp and neck, with occasional involvement of muscle tissue as well. Numerous secondarily altered lymph nodes of the neck and multiple tumour infiltrates in the liver were also seen. A skin biopsy from the scalp was performed Figure (2). Histopathology showed a tumoral lesion composed of irregular, anastomosing vascular spaces and an increased number of surrounding endothelial cells with hyperchromatic, atypical nuclei. The clinical and pathological features corresponded to a typical presentation of angiosarcoma (AS). The patient had an inoperable disseminated disease and palliative chemotherapy with paclitaxel was initiated. After three cycles of therapy, the patient's general condition worsened, and was admitted to a palliative care facility. cAS is a rare vascular malignant tumour that has a high risk of both local and distant metastatic dissemination despite aggressive therapy. It is classified into primary AS that occurs sporadically, usually in the scalp or face, and secondary AS that is most often related to a history of radiation treatment and chronic lymphedema.1 This malignant tumour resembles a “spreading bruise” that varies from blue to red in colour. The diagnosis of cAS is often delayed due to its subtle initial clinical appearance as it is often mistaken for an ecchymosis or haematoma, especially in elderly patients on anticoagulants. Most patients are asymptomatic although some may present with bleeding, oedema, and/or ulceration. Diagnosis is based on clinical examination and histopathological and immunohistochemical analysis. The extent of the disease may be assessed with magnetic resonance imaging or CT.1, 2 AS represents less than 0.1% of all head and neck malignancies but is associated with the highest rate of lymphatic dissemination among all head and neck soft tissue sarcomas.3, 4 AS shows aggressive behaviour and carries a poor prognosis, thus early diagnosis is crucial. The optimal treatment is surgery followed by wide-field radiotherapy. Clear surgical margins are of paramount importance and correlate with better outcome, but the disease is often so extensive at the time of diagnosis that it is not possible to excise.5, 6 Despite inconsistent data regarding chemotherapy, this is usually employed for patients with metastatic or inoperable disease. Doxorubicin-based regimens are most recommended, but recent use of paclitaxel has shown better efficacy compared with doxorubicin.6, 7 Though involvement of the face and scalp is common in cAS, the extent of disease in our case was striking. AS should be considered in the differential diagnosis of violaceous or ecchymotic lesions on the head or scalp in the elderly. All authors contributed to the manuscript conception, design, and writing. All authors read and approved the final manuscript. The authors have not declared a specific grant from any funding agency in the public, commercial or not-for-profit sectors. The authors declare no conflict of interest. This article did not require the approval of the Ethics committee. The patient in this manuscript has given written informed consent to the publication of his case details. Due to privacy and ethical concerns, neither the data nor the source of the data can be made available.

A sudden death, an aortic rupture, and an unexpected cause: a report about suspected child abuse.

All unexpected deaths of children require an autopsy to determine the cause of death. In cases of aortic rupture, the immediate cause of death is easily identified at autopsy. Although the majority of aortic ruptures are caused by high-energy trauma, other causes should not be missed.We present and discuss the case of a 29-month-old child who died suddenly at home. Her recent medical history and the ecchymotic lesions observed on external examination of the body appeared potentially suspicious of physical abuse. The autopsy concluded that death was due to complete rupture of the abdominal aorta with associated vertebral disjunction. At first glance, the overall forensic picture could suggest a traumatic death. However, careful inspection of the retroperitoneum revealed a discrete atypical mass of infiltrative tissue within the hematoma. Histopathological examinations confirmed tumor proliferation of the soft tissues, triggering vascular and spinal injuries. Other paraneoplastic elements or metastases were ultimately revealed (orbital and subcutaneous). Overall, this was a rare and fatal case of abdominal aortic rupture induced by tumors. Due to the mechanisms and the forces needed to cause vertebral dislocations and aortic rupture, the combination of the two is highly suggestive of child abuse when an accidental traumatic history is absent or inconsistent with the injuries. Nevertheless, this case illustrates the importance of a systematic and rigorous forensic examination, rather than ignoring other possible diagnoses.

Urticarial vasculitis associated with post-streptococcal disease in children: a case report

Background: Urticarial vasculitis (UV) is a rare clinicopathologic, especially among children and infants. Most urticarial vasculitis is caused by unknown etiology. Rarely has it been linked to post-streptococcal disease as a non-suppurative complication of a streptococcus infection. Treatment of urticarial vasculitis can be challenging. It is based on the clinical phenotype, systemic symptoms, and/or underlying diseases. Case Presentation: This study reports a case of a child with an itchy but more painful and burning sensations urticarial lesion which persisted for more than 24 hours, left a residual ecchymotic hyperpigmentation lesion when resolved, and was accompanied by systemic symptoms such as joint pain, fatigue, and gastrointestinal symptoms. The symptoms were preceded by signs of pharyngitis one week before the symptoms and supported by an increase in ASO titer that raised the suspicion of a previous recent streptococcal infection. Skin biopsy revealed a leukocytoclastic vasculitis, a specific finding supporting the diagnosis of urticarial vasculitis. The combination of antibiotics, antihistamines, and corticosteroids gave our case a good clinical response and outcome. Conclusion: A high awareness of urticarial vasculitis linked to post-streptococcal diseases is needed to establish prompt treatment and prevent further complications.

Mucocutaneous Manifestations of COVID-19 among Iraqi Patients in Al Diwaniyah Province, Iraq: Case Series Study

Background:The relatively wide distribution of ACE2 receptors all over body tissues suggests the possibility of clinical manifestations other than that of the respiratory tract. The usual incubation period is about 14 days which is often followed by the usual respiratory symptoms and constitutional signs. Globally, additional novel manifestations, including dermatological ones have been reported. Aim:To characterise the skin manifestations in patients with COVID-19 in Al Diwaniyah Province, mid-Euphrates region of Iraq.Method: The present case series study included 54 patients with COVID-19 and a variety of skin manifestations. Those patients visited the dermatology unit at Al Diwaniyah teaching hospital, Al Diwaniyah province, Iraq during the period of the study. The study started in July 2020 and ended in June 2021.Results: The most common features were those of morbilliform eruptions accounting for 18.5% of cases followed by urticarial lesions accounting for 13.0% of cases for followed by ecchymotic pruritic lesion (11.1%). Other features such as oral ulceration and vesicular lesions were also seen in 9.3% of cases. All the body was involved in 29.6% followed by tongue and lip involvement. Morbilliform eruption was the most common diagnosis followed by acute urticaria, herpes simplex, leukocytoclastic vasculitis and then by a variety of other skin manifestations. Conclusion: Skin manifestations in association with COVID-19 were highly variable with onset and duration which could be due to infection, drug reaction or immune mechanisms.

Congenital Radial Nerve Palsy in a Preterm Baby—A Case Report

AbstractCongenital radial nerve palsy is a rare condition seen in newborns. It is thought to occur due to compression of upper arm against the pelvic rim in the intrauterine period. We report one such case of congenital radial nerve palsy in a preterm neonate with a classical ecchymotic skin lesion in the upper arm accompanying the wrist drop. The condition has a good prognosis with spontaneous recovery happening within 6 months in most cases.

Daily follow-up of a scary onset of ecchymotic purpuric lesions in an infant

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Al-Muriesh M, Liu J, Du H, et al. Daily follow-up of a scary onset of ecchymotic purpuric lesions in an infant. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2022;39(4):806-808. doi:10.5114/ada.2022.118925. APA Al-Muriesh, M., Liu, J., Du, H., Wu, S., Wu, T., & Sun, Y. et al. (2022). Daily follow-up of a scary onset of ecchymotic purpuric lesions in an infant. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 39(4), 806-808. https://doi.org/10.5114/ada.2022.118925 Chicago Al-Muriesh, Maher, Juan Liu, Hongxia Du, Shidi Wu, Ting Wu, Yanhong Sun, and Changzheng Huang. 2022. "Daily follow-up of a scary onset of ecchymotic purpuric lesions in an infant". Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii 39 (4): 806-808. doi:10.5114/ada.2022.118925. Harvard Al-Muriesh, M., Liu, J., Du, H., Wu, S., Wu, T., Sun, Y., and Huang, C. (2022). Daily follow-up of a scary onset of ecchymotic purpuric lesions in an infant. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 39(4), pp.806-808. https://doi.org/10.5114/ada.2022.118925 MLA Al-Muriesh, Maher et al. "Daily follow-up of a scary onset of ecchymotic purpuric lesions in an infant." Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, vol. 39, no. 4, 2022, pp. 806-808. doi:10.5114/ada.2022.118925. Vancouver Al-Muriesh M, Liu J, Du H, Wu S, Wu T, Sun Y et al. Daily follow-up of a scary onset of ecchymotic purpuric lesions in an infant. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2022;39(4):806-808. doi:10.5114/ada.2022.118925.

Acute hemorrhagic edema of infancy

Acute hemorrhagic edema of childhood, also called acute hemorrhagic edema of infancy (AHEI) or Finkelstein-Seidlmayer disease is a vasculitis of small blood vessels. The etiology of the disease is unknown, but various reports in the literature indicate precursor triggers including a preceding infectious disease. This article presents a clinical observation of an 8-month-old boy with ecchymotic skin lesions on legs and ears as well as genital edema, with a history of mild upper respiratory infection two weeks before referral. Laboratory findings were normal. After a few days, he was discharged without particular treatment. Despite the low prevalence of this disease, it is important to consider it during examinations due to the clinical nature of the diagnosis. Based on clinical and laboratory findings, a diagnosis of AHEI was made. We decided not to perform any therapy, and after about two weeks lesions had a self-limited resolution. The child was monitored clinically for about six months, and he did not present any relapse of the disease during the follow-up period. This patient was admitted to the hospital, underwent important laboratory tests, and was evaluated by multiple subspecialty services prior to diagnosis. While keeping in mind more worrisome diagnoses, physicians should consider the diagnosis of AHEI in well-appearing young children with purpuric lesions on the face and ears and non-pitting edema of the extremities. Awareness and early recognition of AHEI may prevent hospital admission, invasive workup, and parental and physician concern. Key words: acute hemorrhagic edema of infancy, Finkelstein-Seidlmayer disease, vasculitis

Novel Hemorrhagic Dermatologic Toxicity Associated with Bruton's Tyrosine Kinase Inhibitor Therapy

Background:Bruton Tyrosine Kinase inhibitors (BTKi), including ibrutinib and acalabrutinib, are an integral part of the treatment paradigm for many B-cell malignancies including chronic lymphocytic leukemia (CLL), mantle cell lymphoma (MCL), and Waldenstrom macroglobulemia (WM). Dermatologic toxicities associated with drugs in this class including petechiae, easy bruising, panniculitis, folliculitis, and aphthous ulcerations have been previously documented (Sibaud et al Am J Clin Dermatol. 2020). The ecchymotic lesions noted in this recent review by Sibaud et al were noted to mimic solar purpura with discrete areas of bruising or hematoma. In the present case series, we present a cohort of patients experiencing an array of skin toxicities during treatment with ibrutinib or acalabrutinib including instances of striking confluent ecchymotic skin lesions.Methods:A retrospective chart review was conducted on patients treated within our health system who had received ibrutinib, acalabrutinib or zanubrutinib treatment. IRB approval was obtained prior to collection of clinical data. Patients who had a dermatologic toxicity including petechiae, ecchymoses, hematoma or vasculitis were identified. Patients were excluded if they were receiving BTKi for graft versus host disease or an indication other than CLL or lymphoma, or if there were insufficient records. Data collection included the BTKi agent and dosing utilized, the age at onset of dermatologic toxicity, the time from initiation of BTKi therapy to the development of dermatologic toxicity, and subsequent treatments following BTKi cessation (if any). Data was compiled and descriptive statistics were obtained.Results:Patients had a median age of 73; five patients were male and two female. Diagnoses included CLL (n = 3), MCL (n = 3), and WM (n = 1). Three were treated with acalabrutinib while 4 received ibrutinib. Two patients received combination therapy with ibrutinib, one with ublituximab and one with ixazomib. The average time to onset of skin toxicity was sooner in those taking acalabrutinib (63 days) versus ibrutinib (642 days). Two of the acalabrutinib-related events were documented within 1 month of therapy initiation. Skin biopsy on one patient treated with acalabrutinib revealed vascular ectasia with non-occlusive thrombotic vasculopathy. Following development of these skin toxicities, therapy with the BTKi was discontinued in only 2 of 7 patients. Three patients were transitioned to an alternative BTKi and two were continued on therapy without modification and without further clinical deterioration.Conclusion:While dermatologic toxicity associated with use of ibrutinib and acalabrutinib has been previously described, this cohort represents, to our knowledge, the first documentation of large confluent BTKi- associated ecchymoses. While several patients in this cohort were transitioned to an alternative BTKi or to a different therapeutic class entirely at the onset of dermatologic toxicity, two continued on the implicated BTKi without alteration in therapy. As demonstrated by these varied approaches, management of BTKi therapy following development of dermatologic toxicity is not standardized, with optimal management determined on an individualized basis through discussion and joint decision making with the patient. [Display omitted] DisclosuresWilliams: Janssen: Consultancy, Research Funding; Pharmacyclics: Research Funding. Flowers: Venthera: Current Employment.

PULMONARY EMBOLISM CASES WHICH OCCURRED UNDER ENOXAPARIN SODIUM 4000 IU PROPHYLAXIS

TOPIC: Pulmonary Vascular Disease TYPE: Global Case Reports INTRODUCTION: Some surgical based guidelines recommends standart 4000 IU Enoxaparin for VTE prophylaxis. However fixed dose enoxaparin will often fail to achieve therapeutic levels, since for therapeutic anticoagulation, enoxaparin is dosed based on weight (1mg/kg). To draw attention to this issue, we presented 3 cases who developed PE while receiving 4000 IU Enoxaparin prophylaxis. CASE PRESENTATION: Cases Case 1:A 27-year-old, 72 kilogram male patient, who had no known chronic disease history, was using Enoxaparin sodium 4000 international units (IU) regularly once a day after the meniscus operation. Complaints of back pain and shortness of breath developed two weeks after the operation In the computed tomography pulmonary angiography(CTPA), filling defects in the middle and lower lobar branches of the right lung and extending to the lingular segment of the upper lobe of the left lung were seen. The patient was followed up in our department with the diagnosis of bilateral lobar pulmonary embolism (PE).Case 2:An 80-year-old 65-kilogram female patient with a known chronic obstructive pulmonary disease, atrial fibrillation (AF), hypertension, was using a new generation oral anticoagulant (NOAC) due to AF. NOAC was discontinued upon the development of ecchymotic lesions in the body, and Enoxaparin sodium 4000 IU was added to the treatment once a day.. Three weeks after the treatment change, the patient was admitted to the emergency department with the complaint of dyspnea, and a thrombus extending from the distal of both main pulmonary arteries to the bilateral lower and upper lobe bronchial artery was detected in the CTPA, and he was followed up in our service with the diagnosis of massive PE. DISCUSSION: Case 3: An 81 years old, 67-kilogram female patient with a diagnosis of hypertension and Alzheimer's disease admitted to the hospital with complaints of shortness of breath and swelling in the legs for a week. Seven months ago, Enoxaparin sodium 4000 IU was planned twice a day in an external center due to pulmonary embolism. The patient continued to use LMWH 4000 IU once a day after the 3rd month of his own request. CTPA revealed filling defects in the right pulmonary artery upper lobe posterior and lower lobe posterobasal segments. Lower extremity venous Doppler ultrasonography revealed deep vein thrombus (DVT). When compared with previous examinations, it was observed that pulmonary embolism had newly developed and the patient was followed up with segmental PE + DVT diagnoses. CONCLUSIONS: Although low-dose LMWH treatment is recommended in some guidelines and drug package insert for PE prophylaxis, the cases we have presented suggest that it would be safer to consider the patient's weight when administering LMWH prophylaxis. REFERENCE #1: Prophylactic Enoxaparin Dosing in Obese Orthopedic Patients: A Literature SearchVan N Tran 1, Ilya Varfolomeev 2, Geoff Hill 3 DISCLOSURES: No relevant relationships by MELTEM GUNDUZ, source=Web Response No relevant relationships by H.Canan Hasanoglu, source=Web Response

Psychiatric Profile and Response to Combined Pharmacologic and Psychotherapeutic Treatment in Psychogenic Purpura.

Objective: Psychogenic purpura is a rare psychocutaneous entity characterized by painful atraumatic, ecchymotic, and purpuric lesions that commonly occur in young women. The objective of this study is to describe the clinical presentation, psychiatric profile, and response to therapy (pharmacologic and psychotherapeutic) in patients with psychogenic purpura.Methods: Twenty-three patients, referred from various clinical departments with unexplained purpura or ecchymotic lesions, were assessed in the department of psychiatry of a tertiary care institute in eastern India over a period of 3 years (May 1, 2017, to April 30, 2020). Relevant systemic evaluation and routine biochemical and laboratory tests including complete blood count, bleeding time, clotting time, prothrombin time, coagulation profile, and platelet function test were conducted for all patients to rule out an underlying organic cause. Associated psychiatric comorbidities were diagnosed as per the International Classification of Diseases, 10th edition. All patients who were eventually diagnosed with psychogenic purpura received appropriate treatment (pharmacologic and psychotherapy) and were followed up for 1 year.Results: Seven female patients (age range, 14-70 years, mean age = 30.28 ± 17.42 years) were diagnosed with psychogenic purpura. All patients had significant stressors prior to the appearance of lesions. Facial involvement was reported in 2 patients (28.6%). Multiple sites were affected in 4 patients (57.1%). The underlying psychiatric conditions diagnosed were depressive disorder (42.9%), generalized anxiety disorder (28.6%), dissociative convulsion disorder (14.3%), and panic disorder (14.3%). Associated personality disorder was noted in 2 patients (28.6%). All patients were started on selective serotonin reuptake inhibitors and concurrent psychotherapy. A short course of benzodiazepine was used in all patients and was subsequently tapered off. At 1-year follow-up, 2 patients reported recurrences, while others continued to do well with no similar episodes.Conclusions: Appropriate psychiatric evaluation and necessary intervention in patients with psychogenic purpura lead to improved patient outcomes.