Identical Clinical Presentation Research Articles

Secondary nummular headache: Are they more common thanwe thought?

To provide a detailed description of symptomatic nummular headache (NH) and to compare them with primary cases in a large series. While most published cases of NH are primary headache, some 'secondary' cases have been reported since its initial description. It remains uncertain why identical clinical presentations can result from primary and 'secondary' etiologies. Thanks to the possibility of offering specific treatments for symptomatic NH, it is crucial to be able to distinguish between them effectively. This monocentric retrospective study included a cohort of patients diagnosed with NH according to the International Classification of Headache Disorders, Second (ICHD-2) and Third Editions (ICHD-3), and the Pareja etal. first description, over a 20-year period (2002 to 2022). Established ICHD-3 diagnoses were used for each symptomatic case. Causality was attributed if (i) headache had developed in close temporal relation to other symptoms and/or clinical signs, or had led to its diagnosis, and (ii) either the headache had significantly worsened in parallel with other symptoms or clinical or radiological signs of worsening of the underlying disease, or the headache had resolved after treatment of the presumed causative disorder. Symptomatic NH were divided into two groups: "definite" or "probable." A comparison between the "primary" and "secondary" groups is presented. A total of 131 patients (88, 67.2% females) were included in the study. The median (interquartile range) age at onset of symptoms was 52 (36-63.2) years. In all, 34 patients (25.9%) were diagnosed as symptomatic NH (nine post-traumatic, seven attributed to a disorder of the cranial bones, six due to intracranial neoplasia, five attributed to arachnoid cysts, three attributed to vascular malformations, two due to cutaneous disturbances, and two attributed to hypertension). Eight patients were classified as "definite symptomatic NH" and 26 as "probable symptomatic NH." Neuroimaging was performed in all cases. Any previous headache (52.9% vs. 29.9%; p = 0.016), a remote head trauma (26.5% vs. 9.3%; p = 0.015), and a longer disease duration (18 vs. 12 months; p = 0.036) were more likely in patients with symptomatic NH. Preventive treatment was more effective (achieved >50% reduction in monthly headache days) in patients with symptomatic NH (72.2% vs. 30.3%; p = 0.002) due to a cause-specific treatment. Symptomatic NH are frequent. The presence of any previous headache or remote head trauma may suggest a diagnosis of symptomatic NH; however, as certain NH might be an early symptom of intracranial mass lesions, neuroimaging is necessary. Finding the cause of NH is essential to offer the most effective targeted treatment.

Prenatal dispositions and genetic analysis of monozygotic female twins with suprasellar cysts and hydrocephalus: A case report

IntroductionWe present a unique case of monozygotic female twins with virtually identical clinical and radiological presentations of supratentorial hydrocephalus and cystic formations from the suprasellar cistern.DiscussionEvaluating genetic predispositions and prenatal exposures is crucial for hydrocephalus in twins. Familial cases imply a genetic contribution to the development of these anomalies, including chromosomal abnormalities and specific variants linked to arachnoid cyst formation in various syndromes. Extensive genetic analyses found no pathogenic variants in the twins. Prenatal exposure to anti-epileptic medication was known during pregnancy and may be associated with fetal abnormalities, but not central nervous system (CNS) malformations, and was therefore not considered the cause of the condition in the twins. The twins presenting simultaneously with hydrocephalus caused by suprasellar cysts (SAC) underwent a two-step surgical management: initial ventriculoperitoneal shunt (VPS) placement followed by fenestration. Postoperative imaging showed cyst reduction, but a secondary VPS was necessary in both cases.ConclusionGenetic analysis is less likely to identify a monogenic etiology in non-syndromic cases of SACs, which are assumed to be multifactorial. There is no established evidence linking a teratogenic effect of anti-epileptic drugs to CNS malformations. Moreover, the surgical treatment of this complex condition constitutes a point of discussion.

Spontaneous bilateral tubal ectopic pregnancy: A case report

Unilateral tubal ectopic pregnancies (UTEP) are commonly encountered by physicians. Bilateral tubal ectopic pregnancies (BTEPs), however, are rare and due to the identical clinical presentations of BTEP and UTEP, there is a significant degree of diagnostic difficulty for the former, requiring a high index of suspicion. It should be considered a possibility in any newly pregnant woman of child-bearing age. The purpose of this article is to provide the reader with an example of a clinical presentation of BTEP, and a discourse on management of these patients. We present a case of a 27-year-old patient, who was seen at the emergency department of the Queen Elizabeth Hospital, Barbados, with signs and symptoms of a ruptured ectopic pregnancy. Intraoperative findings included a ruptured left ectopic pregnancy and an intact right fallopian tubal ectopic pregnancy. Left salpingectomy and right salpingostomy were performed, conserving the intact tube; her recovery was solely complicated by a superficial surgical site infection.

A Rare Cause of Liver Fibrosis in an Adolescent Woman

A Rare Cause of Liver Fibrosis in an Adolescent Woman

Trigeminal neuralgia associated with a solitary demyelinating pontine lesion: A case report

Trigeminal neuralgia associated with brainstem lesions is currently considered as a rare condition and only few patients have been reported so far in literature. Tohyama and colleagues recently proposed the nosological entity of trigeminal neuralgia associated with solitary pontine lesion, trying to categorize it as a new clinical syndrome on its own. Based on this description, trigeminal neuralgia associated with solitary pontine lesion patients have an identical clinical presentation compared to other patients with trigeminal neuralgia but have a solitary pontine lesion. The nature of the pontine lesion has been attributed to several etiologies, including ischemia, demyelination or previous pontine viral neuritis. In those patients with a putative demyelinating lesion, a definite diagnosis of multiple sclerosis cannot be made due to the lack of dissemination in space. Very little is known in relation to the cerebrospinal fluid characteristics of this population of patients.

Recurrent post-partum rhombencephalitis associated with anti-centromere antibody: a case report

BackgroundRhombencephalitis (RE) is a serious condition of the brain with multiple etiologies. We report a unique case of recurrent, postpartum RE that is associated with positive anti-centromere antibody (ACA). A discussion of the case, current literature on autoimmune RE and related autoantibodies are reviewed.Case presentationA healthy 33-year-old Caucasian patient (gravida 2, para 2) had two episodes of progressive focal neurological deficits during postpartum periods. Signs and symptoms included right-sided dysmetria, adiadochokinesia, weakness, ataxia, and photophobia. MRI revealed rhombencephalitis involving the mesencephalon of the brainstem. Extensive and comprehensive investigations using blood and cerebrospinal fluid (CSF) were consistently positive only for ACA. The first episode was successfully treated with empiric antimicrobial agents and steroid. Given the negative infectious work up with the prior episode and the nearly identical clinical presentations, the second episode was treated with corticosteroid only. This led to complete resolution of her symptoms and reversal of the brain magnetic resonance imaging (MRI) lesions.ConclusionTo the author's knowledge, this is the first report of a primary autoimmune RE during postpartum period that is associated with ACA. Immunologic causes should be considered early with any encephalitis. Given the risk of recurrence, relapse, and neurologic deterioration, regular monitoring is recommended, especially for female patients of child-bearing age. Consistent with the current literature on autoimmune RE, steroid seems to be an effective treatment for ACA-associated RE.

Metabolic differentiation of early Lyme disease from southern tick-associated rash illness (STARI).

Lyme disease, the most commonly reported vector-borne disease in the United States, results from infection with Borrelia burgdorferi. Early clinical diagnosis of this disease is largely based on the presence of an erythematous skin lesion for individuals in high-risk regions. This, however, can be confused with other illnesses including southern tick-associated rash illness (STARI), an illness that lacks a defined etiological agent or laboratory diagnostic test, and is coprevalent with Lyme disease in portions of the eastern United States. By applying an unbiased metabolomics approach with sera retrospectively obtained from well-characterized patients, we defined biochemical and diagnostic differences between early Lyme disease and STARI. Specifically, a metabolic biosignature consisting of 261 molecular features (MFs) revealed that altered N-acyl ethanolamine and primary fatty acid amide metabolism discriminated early Lyme disease from STARI. Development of classification models with the 261-MF biosignature and testing against validation samples differentiated early Lyme disease from STARI with an accuracy of 85 to 98%. These findings revealed metabolic dissimilarity between early Lyme disease and STARI, and provide a powerful and new approach to inform patient management by objectively distinguishing early Lyme disease from an illness with nearly identical symptoms.

Unique neuro-ophthalmic presentation of gun pellet injury.

We describe a unique case of orbital gunshot injury with isolated intraorbital pellets lodged symmetrically in the two apices, causing identical clinical presentation, and absence of any associated globe or cerebral injury. He developed bilateral complete third nerve palsy with bilateral traumatic optic neuropathy. The optic nerve strut prevented the pellets from going into the brain on both the sides.

Isolated ischemic colitis may mimic occluding cancer in elderly patients

At our unit, we have treated two consecutive cases of ischemic colitis (IC) involving the cecum alone, with an identical clinical, radiological and histological presentation, which highlight the role of this clinical entity as a cause of bowel occlusion. Moreover, we observed that determining the appropriate treatment strategy may be challenging, especially in elderly patients, because of difficulty in interpreting the clinical features and choosing the correct surgical procedure. Patient 1—An 89-year-old male was admitted to our unit 12 h after the onset of acute right lower quadrant abdominal pain and vomiting. Comorbidities included the following: atrial fibrillation, hypertensive heart disease, and hyperuricemia. On examination, the patient was dehydrated and febrile (38 C). Blood tests revealed leukocytosis (13,800), hypokalemia (3.4 mEq/L), and high C-reactive protein (CRP) (213 mg/L). A partially occluding cecal mass was detected by computed tomography (CT) scan. At emergency laparotomy, an endoluminal mass, approximately 4–5 cm in diameter and hard-elastic in consistency, could be felt at the level of ileocecal valve. The surface of the colon did not show signs of infiltration or ischemia and this strongly suggested occluding neoplasia. Right colectomy was therefore performed. Histological examination revealed transmural acute inflammatory infiltrate with massive submucosal edema, vascular congestion, and areas of hemorrhage. Focal well-defined areas of mucosal ischemic necrosis were present. Skip lesions surrounding these areas presented subtle ischemic changes, namely variability in crypt size, crypt foreshortening, and acute inflammation (Fig. 1a, b). No signs of mesenteric vascular occlusion were documented. The patient’s postoperative course was uneventful and he was discharged after 6 days. Six months after surgery, the patient enjoys good health. Patient 2—A 92-year-old female was referred to our unit due to acute abdominal pain in the lower right quadrant which had begun a few hours before admission and had been preceded by low-grade fever, vomiting, and diarrhea. Comorbidities included atrial fibrillation, ischemic heart disease and hypothyroidism, while at admission, fever (37.5 C), leukocytosis (16,000), high CRP (144 mg/L), and sideropenic anemia (Hb 7.9 g/dL, Iron 40 mcg/dL) were found. An abdominal CT scan showed mechanical distension of the ileum and thickened adherent loops without peritoneal effusion. Moreover, next to the ileocecal valve, a neoplastic-like mass was observed. The patient underwent urgent laparotomy and an endoluminal mass with the same characteristics as in case 1 could be felt in the cecum. There was an exophytic plaque on the surgical specimen (Fig. 2). The histological features were similar to those in case 1 (Fig. 1c, d). The patient was discharged after 9 days, and she is asymptomatic 12 months after surgery. In a few published studies, IC has been characterized by limited extension of the ischemic area [1, 2], and the histological findings of our cases can be ascribed to isolated C. R. Asteria (&) L. Troiano Department of Surgery and Orthopaedics, General Surgery Unit Asola, Carlo Poma Hospital Mantua, 80th Fanteria Square, 1, 46041 Asola, Mantua, Italy e-mail: corrado.asteria@libero.it

P-821 - Brain tumor patient who is primarily directed to psychiatrictreatment-case report

Psychiatric symptoms are common clinical manifestations of brain tumors. Brain tumors that manifest symptoms of creased intracranial pressure, focal neurological signs, and routine diagnostic procedures diagnosed by a neurologist, or less commonly,neurosurgeons. However, “neurologically silent” tumors, are those in which the psychiatric symptoms occur as the first sign of a brain tumor.Patients are then referred psychiatrist. A case report. This paper presents a patient diagnosed with a brain tumor, which was primarily addressed to a psychiatrist for treatment for mental disorders, while the neurological findings were without focal outage. The above presentation the authors want to acknowledge that psychiatric symptoms /disorders in cancer brain are not specific enough and may have an identical clinical presentation as well as functional psychiatric disorders, and therefore, in patients with rapid early psychiatric symptoms, in patients with unexpected changes in mental status or the sudden occurrence of headaches, as well as therapy-resistant psychiatric disorders, you should always bear in mind the possibility of the existence of associated brain tumors.

Japanese encephalitis (JE). Part I: clinical profile of 1,282 adult acute cases of four epidemics

Japanese encephalitis (JE) is numerically the most important global cause of encephalitis and so far confirmed to have caused major epidemics in India. Most of the reported studies have been in children. This largest study involving only adults, belonging to four epidemics, is being reported from Gorakhpur. The aim of this study is to detail the acute clinical profile (not viral) outcome and to classify the sequelae at discharge. This prospective study involved 1,282 adult patients initially diagnosed as JE admitted during the epidemics of 1978, 1980, 1988, and 1989, on identical clinical presentation and CSF examination. In the meantime, the diagnosis of JE was confirmed by serological and/or virological studies in only a representative number of samples (649 of 1,282 cases). Eighty-three left against medical advice (LAMA) at various stages, so 1,199 of 1,282 were available for the study. Peak incidence of [1,061 of 1,282 (83%)] of clinically suspected cases was from September 15 to November 2. Serum IgM and IgG were positive in high titers in 50.87% (330 of 649) and IgM positive in CSF in 88.75% (109 of 123) of the cases. JE virus could be isolated from CSF and brain tissue in 5 of 5 and 4 of 5 samples, respectively. Altered sensorium (AS) in (96%), convulsions (86%), and headache (85%) were the main symptoms for hospitalization by the third day of the onset. Other neurological features included hyperkinetic movements in 593 of 1,282 (46%)-choreoathetoid in 490 (83%) and bizarre, ill-defined in 103 (17%). The features of brain stem involvement consisted of opsoclonus (20%), gaze palsies (16%), and pupillary changes (48%) with waxing and waning character. Cerebellar signs were distinctly absent. Dystonia and decerebrate rigidity was observed in 43 and 6%, respectively, paralytic features in 17% and seizures in 30%. Many non-neurological features of prognostic importance included abnormal breathing patterns (ABP) (45%), pulmonary edema (PO) (33%), and upper gastrointestinal hemorrhage (UGIH) (16%). Injection dexamethasone was used in 1978 in all 208 cases, including 21 of PO. Patients were later randomized alternately in dexa and non-dexa groups. Forty-six cases of PO from the non-dexa group were transferred to the dexa group as an ultimate life-saving measure. Thus, it was administered in 737 of 1,199 patients including 529 patients from the later epidemics in doses of 4 mg IV every 8 h for 7 days. Of 1,199, 462 did not receive it. There was no significant difference in mortality (p > 0.05) between the dexa (42.47%) and the non-dexa group (42.86%). All PO cases expired; so after the exclusion of the PO cases from dexa group, the difference of 6.14% (42.86 and 36.72) became significant (p < 0.01) (511 of 1,199 (43%) expired, [320 of 511 (63%) died within 3 days of hospitalization]). Out of a total of 1,199 patients treated, 688 (57%) were discharged; 23 of 688 (3%) without any sequelae and 665 of 688 (97%) with neuropsychiatric deficits classified into nine groups. During the four epidemics, the diagnosis of JE was basically on identical clinical presentation of acute encephalitic syndrome (AES) consisting of (1) abrupt onset of fever, headache, and AS, (2) dystonias and various movement disorders, (3) opsoclonus and gaze palsies, (4) CSF findings, and (5) the presence of residual neuropsychiatric and neurological features in the survivors.

Epidemic Optic Neuropathy Is Evident in the Somalian Population

Optic neuropathy epidemics have proven to be a serious public health problem around the world. Recently, documented outbreaks have occurred in Cuba and Tanzania, with almost identical clinical presentation. Investigations of both epidemics have implicated nutritional deficiencies as part of a multifactorial etiology, and thus, it is proposed that there may be many undetected epidemics in other food-deprived nations. Somalia, a country subject to prolonged droughts and civil war, may be at particular risk of nutritional deficits. We conducted a case series in Mogadishu, the Somalian capital, with the aim of identifying and characterizing any cases of epidemic optic neuropathy. Cases were recruited at the Al-Noor Eye Hospital, Mogadishu, between 2002 and 2004. Individuals were screened by trained ophthalmic nurses, and a full ophthalmic examination was undertaken by an experienced ophthalmologist. Patients also completed a lifestyle questionnaire to identify any common risk factors. One hundred five acute cases of optic neuropathy were identified. Progression from hyperemia to pallor of the optic discs and greatest visual loss occurred over the first month. Our findings are similar to those reported in the Tanzanian epidemic, including involvement of young patients (mean age: 24 ± 5.3 years) and evidence of peripheral neuropathy. Epidemic levels of optic neuropathy are evident in Somalia. The extent of visual loss in the first month emphasizes the need to initiate treatment early in the course of the disease. Training and establishing health surveillance systems in community clinics may form a central component to this strategy.

Autoimmunity to Desmocollin 3 in Pemphigus Vulgaris

Pemphigus vulgaris is a blistering disease associated with autoantibodies to the desmosomal adhesion protein, desmoglein 3. Genetic deficiency of desmoglein 3 in mice mimics autoimmunity to desmoglein 3 in pemphigus vulgaris, with mucosal-dominant blistering in the suprabasal layer of the epidermis. Mice with an epidermal-specific deletion of desmocollin 3, the other major desmosomal cadherin isoform expressed in the basal epidermis, develop suprabasal blisters in skin that are histologically identical to those observed in pemphigus vulgaris, suggesting that desmocollin 3 might be a target of autoantibodies in some pemphigus vulgaris patients. We now demonstrate that desmocollin 3 is an autoantigen in pemphigus vulgaris, illustrated in a patient with mucosal-dominant blistering. Six of 38 pemphigus vulgaris and one of 85 normal serum samples immunoprecipitate desmocollin 3 (P = 0.003). Incubation of patient IgG with human keratinocytes causes loss of intercellular adhesion, and adsorption with recombinant desmocollin 3 specifically prevents this pathogenic effect. Additionally, anti-desmocollin 3 sera cause loss of keratinocyte cell surface desmocollin 3, but not desmoglein 3 by immunofluorescence, indicating distinct cellular pathogenic effects in anti-desmocollin and anti-desmoglein pemphigus, despite their identical clinical presentations. These data demonstrate that desmocollin 3 is a pathogenic autoantigen in pemphigus vulgaris and suggest that pemphigus vulgaris is a histological reaction pattern that may result from autoimmunity to desmoglein 3, desmocollin 3, or both desmosomal cadherins.

Subkutanes Granuloma annulare: eine nicht zu vergessende Differenzialdiagnose bei expansiven (Weichteil-) Läsionen an den unteren Extremitäten von jungen Kindern

Expansive lower leg lesions in children include numerous, even malignant, entities. Good differential diagnostic knowledge is extremely important in those conditions in order to prevent unnecessary biopsy. Therefore, our own observations of a not particularly rare pseudotumorous soft-tissue disease are presented and the value of ultrasonography is emphasized. The imaging material (sonograms in all, MRI and radiograms in the first 4 and 3 patients, respectively) and the clinical charts of 7 young children (4 females, 3 males; aged 28-65 months) were analyzed retrospectively. All lesions were pretibial, firm, indolent, non-movable, and without inflammatory signs. They had developed spontaneously. Laboratory tests were normal. Ultrasound demonstrated all lesions located subcutaneously, homogeneously echopoor with indistinct borders and only little increased perfusion. On MRI they presented with low signal in T1, high in T2 and marked contrast enhancement. No intraosseous changes or calcifications were found. Histological proof in the first 2 patients disclosed subcutaneous annular granuloma. Based on an identical clinical and sonographic initial presentation, biopsy and additional imaging were dispensed in the later patients. Their clinical course with only sonographic controls was as expected. When dealing with expansive lower leg soft-tissue lesions in young children, the presented typical clinical and sonographic findings should give rise to consideration of the benign entity of subcutaneous annular granuloma and primary monitoring of those patients with only ultrasound.

Variability in recovery from aphasia

Clinicians have long recognized the enormous variability of recovery among patients with aphasia. Accordingly, the identification of specific factors most important in determining the extent of recovery has been the subject of many investigations. Yet, the reasons for two patients of the same age, nearly identical clinical presentations, and similar MRI findings having completely dissimilar recoveries are still unknown. It remains difficult for a clinician to make a valid prognosis of language recovery in an individual patient. This article provides a review of aphasia-recovery research and a framework for approaching the variability of recovery in clinical practice.

An artificial intelligence tool to predict fluid requirement in the intensive care unit: a proof-of-concept study

IntroductionThe goal of personalised medicine in the intensive care unit (ICU) is to predict which diagnostic tests, monitoring interventions and treatments translate to improved outcomes given the variation between patients. Unfortunately, processes such as gene transcription and drug metabolism are dynamic in the critically ill; that is, information obtained during static non-diseased conditions may have limited applicability. We propose an alternative way of personalising medicine in the ICU on a real-time basis using information derived from the application of artificial intelligence on a high-resolution database. Calculation of maintenance fluid requirement at the height of systemic inflammatory response was selected to investigate the feasibility of this approach.MethodsThe Multi-parameter Intelligent Monitoring for Intensive Care II (MIMIC II) is a database of patients admitted to the Beth Israel Deaconess Medical Center ICU in Boston. Patients who were on vasopressors for more than six hours during the first 24 hours of admission were identified from the database. Demographic and physiological variables that might affect fluid requirement or reflect the intravascular volume during the first 24 hours in the ICU were extracted from the database. The outcome to be predicted is the total amount of fluid given during the second 24 hours in the ICU, including all the fluid boluses administered.ResultsWe represented the variables by learning a Bayesian network from the underlying data. Using 10-fold cross-validation repeated 100 times, the accuracy of the model in predicting the outcome is 77.8%. The network generated has a threshold Bayes factor of seven representing the posterior probability of the model given the observed data. This Bayes factor translates into p < 0.05 assuming a Gaussian distribution of the variables.ConclusionsBased on the model, the probability that a patient would require a certain range of fluid on day two can be predicted. In the presence of a larger database, analysis may be limited to patients with identical clinical presentation, demographic factors, co-morbidities, current physiological data and those who did not develop complications as a result of fluid administration. By better predicting maintenance fluid requirements based on the previous day's physiological variables, one might be able to prevent hypotensive episodes requiring fluid boluses during the course of the following day.

Late onset Leigh syndrome and ataxia due to a T to C mutation at bp 9,185 of mitochondrial DNA

A T-to-C missense mutation at nucleotide position 9,185 in the protein-coding ATP6 gene of the mitochondrial genome was present at high heteroplasmy in members of a Canadian family with Leigh syndrome with predominant ataxia and peripheral neuropathy. This mutation results in the substitution of a proline residue for an evolutionary-conserved leucine at position of amino acid 220 near the carboxyl terminus of the mitochondrial protein. The index patient and brother, who had an identical clinical presentation, had >90% mutant mtDNA in cultured skin fibroblasts, lymphocytes, and whole blood. Their mother and a maternal uncle, symptomatic with a peripheral neuropathy alone, had 86% and 85% heteroplasmy, respectively. Symptomatic maternal cousins with early onset revealed 90% and 91% mutant mtDNA in all tissues analyzed. Studies of lymphoblasts from the asymptomatic maternal grandmother and eldest brother of the proband were heteroplasmic for mutant mtDNA with 56% and 17%, respectively. Biochemical analysis demonstrated normal respiratory chain enzyme activity in muscle and fibroblasts, normal ATP synthesis, but reduced oligomycin-sensitive H(+)ATPase in cultured lymphoblast mitochondria. We propose that the 9,185T > C mtDNA mutation is pathogenic even though the initial phenotype is mild and the biochemical phenotype not easily detectable.

A case of recurrent Miller Fisher syndrome mimicking botulism

Miller Fisher syndrome (MFS) is a rare and usually monophasic polyradiculoneuropathy characterised by ophthalmoplegia, decreased or absent tendon reflexes, and ataxia. The objective of this study was to report a case of recurrent MFS with a clinical presentation virtually indistinguishable from botulism. The patient was a young man with two episodes of increasing external ophthalmoplegia, ptosis, and ataxia with a long asymptomatic interval in between. The second episode occurred after consumption of rotten fish and was accompanied by gastrointestinal symptoms and an anticholinergic syndrome. Very rarely, MFS can present with a recurrent course. The importance of this case of recurrent MFS lies not only in its long asymptomatic period and identical clinical presentation, but also in its instructiveness regarding the differential diagnosis of MFS, particularly life-threatening botulism.

Olanzapine-induced vasculitis

Introduction: Elderly patients are particularly vulnerable to adverse drug reactions as a result of polypharmacy and metabolic changes associated with aging. We present a case of leukocytoclastic vasculitis induced by olanzapine, a medication commonly used in elderly patients. Case summary: An 82-year-old woman was admitted to the extended-care center for short-term rehabilitation after prolonged hospitalization for a pulmonary embolism requiring mechanical ventilation. The pulmonary problem resolved, but her hospitalization and subsequent rehabilitation were complicated by agitated delirium, which was treated with olanzapine and modification of contributory factors. At the time of admission to the rehabilitation facility, the patient had been receiving warfarin for 2 weeks and olanzapine for 6 days. On the eighth day after initiation of olanzapine, erythematous skin lesions developed on dependent areas. The international normalized ratio for warfarin was within the acceptable range; however, because warfarin has been associated with subcutaneous bleeding presenting as petechiae and ecchymosis, subcutaneous enoxaparin was substituted for warfarin. The skin lesions continued to worsen over the next week and developed into palpable lesions. Biopsy of the rash revealed leukocytoclastic vasculitis. In the absence of another cause, olanzapine was discontinued and the rash improved significantly. When the agitation recurred, risperidone was initiated, but the patient experienced dizziness with this agent. Olanzapine was resumed and the skin lesions recurred. Olanzapine was then changed to quetiapine, and the skin lesions improved over the next few weeks. Discussion: Olanzapine is commonly used in elderly patients to control behavioral disturbances associated with dementia, delirium, and other psychiatric disorders. Leukocytoclastic vasculitis is an infrequently reported adverse drug reaction with olanzapine. Its exact pathogenic mechanism is unknown, but both cell-mediated and humoral immunity appear to play important roles. Because drug-induced vasculitis has an identical clinical presentation and identical serologic/pathologic parameters to idiopathic forms of vasculitis, a high index of suspicion is necessary for its accurate diagnosis. Conclusions: Because adverse drug reactions are common in elderly patients taking multiple medications, physicianConclusions:528 should be vigilant when starting new medications and should attempt to eliminate unnecessary medications. Clinicians should be aware of the potential for leukocytoclastic vasculitis in association with olanzapine.

Pulmonary veno-occlusive disease after neoadjuvant mitomycin chemotherapy and surgery for lung carcinoma

Pulmonary veno-occlusive disease (PVOD), an uncommon cause of pulmonary hypertension (PH) has been reported following treatment of a variety of different malignancies with various chemotherapy. We report here the cases of two patients with non-small cell lung cancer (NSCLC) who developed fatal PH after combined treatment with surgery and a mitomycin containing perioperative chemotherapy (PCT). PVOD was documented at autopsy in one patient and was strongly suspected in the other patient who had an identical clinical presentation and in whom the work-up looking for another cause of PH was negative. Mitomycin was incriminated in both cases. Without questioning the potential interest of perioperative chemotherapy in resectable NSCLC, these observations illustrate the risks related to the combination of pneumotoxic chemotherapy and thoracic surgery.