Rare Side Effect Research Articles

Vildagliptin-Associated Bullous Pemphigoid: A Case Report

Objective: Bullous pemphigoid is a rare autoimmune skin disorder characterized by blistering, urticarial lesions, which are sometimes associated with adverse drug reactions. Vildagliptin is an oral anti-diabetic agent that selectively inhibits the dipeptidyl peptidase-4 (DPP-4) enzyme Materials and Methods: A 75-year-old female with a known case of type 2 Diabetes Mellitus, hypertension, and hypothyroidism for the last 10 years presented with pruriginous tense bullous skin lesions over her both palms and soles. There was no mucosal involvement. Further interrogation revealed that she started taking Vildagliptin 5 days ago which was prescribed due to high levels of post-prandial blood sugar level despite already intake of Glimepiride-4 mg and Metformin-3 gm. Results: Vildagliptin was immediately advised to be stopped. She was treated with antihistamines, steroids, and conservative management which led to remission of the blisters Conclusion: Vildagliptin is the probable causative drug for developing bullous pemphigoid skin lesion which shows temporal association in this case as other concomitant drugs has no direct correlation. Therefore physicians must be aware of this rare life-threatening side effect of this medicine and advice patients to visit the hospital even the slightest cutaneous manifestation. Bullous pemphigoid can result in fatal life-threatening conditions if not treated early.

Immune Checkpoint Inhibitors-Associated Generalized Lipodystrophy: Reconstructive Challenges of an Emerging and Distinct Form of Lipodystrophy.

Total and permanent loss of facial and nonfacial fat is a rare side effect of immune checkpoint inhibitors (ICIs). Consequently, effective treatment modalities for patients remain undefined. Here, we discuss the surgical treatment of a patient with both ICI-related acquired generalized lipodystrophy (AGL). We additionally performed a comprehensive literature review (Cochrane, Embase, and MEDLINE) to summarize what is known about ICI-related lipodystrophy and available treatments for this rare complication. A 66-year-old female diagnosed with metastatic lung adenocarcinoma started ICI (pembrolizumab) treatment. She developed generalized lipodystrophy 13 months after her first cycle. Her primary concern was the loss of facial fat volume, which significantly aged her appearance. The patient underwent a 2-staged restoration of her facial fat compartments using dermal grafts from the lower abdomen and medial thighs. The patient recovered uneventfully and was satisfied with the aesthetic improvement at 18 months of follow-up. The authors identified 8 case reports with patients with ICI-AGL. The mean age was 53.63 years, and the mean BMI was 36.72kg/m2. The average onset of symptoms was 7.44 months after ICI initiation. None of the studies described any sort of surgical or nonsurgical options to restore the volume of the facial fat compartments. The management of combined facial and nonfacial lipodystrophy remains challenging due to the lack of suitable autologous fat donor sites. In this report, the authors demonstrate that staged volume restoration can be achieved using autologous dermal grafts from the thigh, making it a viable reconstructive option in this subset of patients.

The Incidence and Severity of Medication Related Osteonecrosis of the Jaws is Similar in Male and Female Mice

Medication related osteonecrosis of the jaws (MRONJ), a rare side-effect of antiresorptive medications, is described as exposed bone in the oral cavity that lasts for at least 8weeks. Most studies report a female predilection for MRONJ; these findings could be due to the increased use of antiresorptives in females, or due to inherent differences between male versus female patients. The purpose of this study was to measure and compare the incidence and severity of osteonecrosis of the jaws (ONJ) between male and female mice. We designed a randomized in-vivo animal study utilizing male and female mice treated with zoledronic acid (ZA). Experimental periodontitis was induced in 24 male and 24 female mice using a silk ligature following administration of saline or a potent bisphosphonate. After 8weeks, animals were evaluated radiographically and histologically. The independent variables were sex (male vs female) and treatment group (ZA vs saline control). Treatment was randomly assigned with balanced distribution between male and female animals. The main outcome variable was ONJ status coded as present or absent. ONJ was defined as present if there was histologic contact between the ligature and the alveolar bone. Secondary outcomes of interest were radiographic and histologic parameters. Statistical differences were analyzed using a two-way analysis of variance with Tukey's post hoc test using a P value of 0.05 for significance. The final sample was composed of 24 vehicle treated and 24ZA treated animals. In vehicle treated animals, 8% of female and 8% of male animals developed ONJ. In ZA treated animals, 83% of female and 92% of male animals developed ONJ. Sex was not associated with the risk (measured as incidence of disease) for developing ONJ or in the radiographic or histologic parameters that were assessed (P values >.1). Sex does not appear to affect the incidence of MRONJ or the severity of the disease as assessed by the radiographic and histologic parameters.

Development of in-silico drug cardiac toxicity evaluation system with consideration of inter-individual variability.

Safety pharmacology examines the potential for new drugs to have unusual, rare side effects such as torsade de pointes (TdP). Recently, as a part of the Comprehensive in vitro Proarrhythmia Assay (CiPA) project, techniques for predicting the development of drug-induced TdP through computer simulations have been proposed and verified. However, CiPA assessment generally does not consider the effect of cardiac cell inter-individual variability, especially related to metabolic status. The study aimed to explore whether rare proarrhythmic effects may be linked to the inter-individual variability of cardiac cells and whether incorporating this variability into computational models could alter the prediction of drugs' TdP risks. This study evaluated the contribution of two biological characteristics to the proarrhythmic effects. The first was spermine concentration, which varies with metabolic status; the second was L-type calcium permeability that could occur due to mutations. Twenty-eight drugs were examined throughout this study, and qNet was analyzed as an essential feature. Even though there were some discrepancies of TdP risk predictions from the baseline model, we found that considering the inter-individual variability might change the TdP risk of drugs. Several drugs in the high-risk drugs group were predicted to affect as intermediate and low-risk drugs in some individuals and vice versa. Also, most intermediate-risk drugs were expected to act as low-risk drugs. When compared, the effects of inter-individual variability of L-type calcium were more significant than spermine in altering the TdP risk of compounds. These results emphasize the importance of considering inter-individual variability to assess drugs.

Hyperammonemic encephalopathy: An unaccounted side effect of 5FU and capecitabine.

e24108 Background: Metabolic encephalopathy is a serious but reversible condition that is characterized by a diffuse impairment of cognitive function due to the overabundance of various metabolites or toxins. Hyperammonemia ( > 80 μg/dL or > 47 μmol/L) is a well-known cause of metabolic encephalopathy and also a rare side effect of 5-Fluorouracil (5-FU) chemotherapy. Constipation and renal failure are two known risk factors for developing hyperammonemic encephalopathy with 5-FU use. Capecitabine is a 5-FU prodrug that is commonly used as a more tolerated and more convenient alternative chemotherapy agent. Despite being less common than with 5-FU, cases of hyperammonemic encephalopathy related to capecitabine use may be missed clinically due to under-testing. Additionally, diarrhea may be misinterpreted as a side effect of chemotherapy instead of an effective tool for identifying early disease and accelerating disease resolution. Methods: A search using Pubmed was conducted on January 4th, 2024 to identify cases of hyperammonemia and metabolic encephalopathy related to 5-Fluorouracil and capecitabine. The search strategy was ("metabolic encephalopathy 5-fluorouracil" OR “hyperammonemia 5-fluorouracil”) AND (“metabolic encephalopathy capecitabine” OR “hyperammonemia capecitabine”). Cases were then organized into a table where factors of the cases were stratified. Results: A total of 59 total cases were identified. Every case where 5-FU was used reported a serum ammonia level, while only 5 of the 9 cases (55.55%) where capecitabine was used reported a serum ammonia level. Additionally, only 9 cases (15.25%) reported bowel movement status with 1 patient presenting with diarrhea, and 5 with constipation. The most common methods for managing metabolic encephalopathy in these patients included: branched chain amino acids (66.10%), discontinuing/changing the chemotherapeutic agent (62.71%), lactulose (37.29%), intravenous hydration (32.20%), and hemodialysis/hemofiltration (13.56%). For the 52 cases that reported it, the average duration of symptoms post-treatment was 2.15 days. Conclusions: A goal in managing patients receiving 5-FU or capecitabine with hyperammonemic encephalopathy is the excretion of ammonia without causing dehydration. This management is seen with the use of lactulose to increase bowel movements in patients with decompensated liver cirrhosis. Of note, 5FU and capecitabine have been shown to cause diarrhea as a grade 3 and 4 adverse effect in 12.7% and 16.6% of patients, respectively. Thus it can be theorized that the diarrhea from 5FU/capecitabine may offset the development of hyperammonemia. This principle could potentially be expanded to benefit patients with a history of chronic constipation. The oversight of hyperammonemia from 5-FU and capecitabine use is both dangerous and diminishes the quality of life from patients who are not proactively treated to prevent encephalopathy.

Research on the Effectiveness of Using a Combined Medication Containing Quercetin, Vitamins C and D, and Zinc in the Treatment and Prevention of Acute Respiratory Viral Infections

The objective: to evaluate the effectiveness of the combined medication, which includes ascorbic acid (vitamin C), vitamin D3 (cholecalciferol), quercetin, and zinc oxide in the treatment and prevention of complications of acute respiratory viral infections (ARVI) at the outpatient level. Materials and methods. 5,982 patients (42.68% men and 57.32% women) aged 18 years and older with symptoms of ARVI participated in the study. The study was conducted in two stages: 1) diagnosis of ARVI and prescribing treatment, including a combined medication; 2) final assessment of the effectiveness, safety and tolerability of therapy. The total duration of participation in the study for one patient was no more than 1 month. In the complex treatment of ARVI at the outpatient level, according to the instructions, 1, 2 or 3 tablets per day were prescribed, depending on the severity of the course of the disease. The duration of treatment was from 5 to 30 days. 1 tablet of the combined medication includes ascorbic acid (vitamin C) – 100 mg, sodium ascorbate – 450 mg (equivalent to ascorbic acid – 400 mg), vitamin D3 (cholecalciferol) – 1000 IU, quercetin – 250 mg, zinc oxide (equivalent to elemental zinc) – 10 mg. Efficacy was evaluated based on the frequency of bacterial complications of ARVI, which required the antibiotic therapy. The safety of the therapy was assessed by the frequency of adverse outcomes and their severity. Results. The main indication for the use of the combined medication was ARVI (83% of patients) without etiological clarification, 5% of patients were diagnosed with COVID-19 and 11% – influenza. In 6% of patients the drug was prescribed for prophylactic purposes and for non-infectious diseases. Clinical manifestations of acute bronchitis were found in 12% of patients with ARVI, acute sinusitis – in 8% of patients. Bacterial complications (pneumonia, otitis, bacterial sinusitis, and bronchitis) in which there is a need to use systemic antibiotics occurred in 4.79% (95% CI: 4.27–5.35%) of ARVI patients which have received the combined medication. The frequency of prescribing systemic antibiotics increased in proportion to the severity of the disease and the age of the patients. Adverse non-serious, rare side effects when using the combined medication were found in 0.56% of patients who participated in the study. Conclusions. The combined medication, which includes ascorbic acid (vitamin C), vitamin D3 (cholecalciferol), quercetin, zinc oxide, has good tolerance and can be recommended to alleviate the condition of patients with ARVI, prevent complications, shorten the duration of treatment and promote faster recovery of the patient.

Cold-associated laryngopharyngeal dysesthesia syndrome after oxaliplatin treatment.

Oxaliplatin is a platinum-group chemotherapeutic agent commonly used in the treatment of colorectal cancer. In addition to hematological and gastrointestinal side effects, laryngopharyngeal dysesthesia associated with cold is reported as a rare side effect. In this article, seven cases with pharyngolaryngeal dysesthesia were presented and the diagnosis and treatment planning were reviewed in the light of literature findings. Patient records of cancer patients with laryngopharyngeal dysesthesia were retrospectively analyzed between 2020 and 2023. Demographic characteristics, presenting complaints, vital signs, physical examination, and laboratory tests of the patients diagnosed with laryngopharyngeal dysesthesia were recorded. Seven patients who had gastrointestinal malignancy and oxaliplatin chemotherapy were diagnosed with laryngopharyngeal dysesthesia. The symptoms most commonly developed due to cold weather. The symptoms of three patients had developed while receiving treatment, while four patients were admitted to emergency service after oxaliplatin infusion. The physical examinations revealed no pathological findings of the allergic reaction at presentation or during follow-up skin. Patients were monitored and nasal oxygen therapy was administered. A 5 mg intravenous infusion was given for anxiety symptoms in three patients. Patients were discharged after 4 hours of follow-up with resolution of all symptoms. Laryngopharyngeal dysesthesia should be kept in mind in patients treated with oxaliplatin and presenting with shortness of breath and a feeling of suffocation after cold exposure.

Exploring the Uncharted Territory: Abacavir in HIV Treatment Unveils Rare Side Effect - A Focus on Hypophosphatemia

Exploring the Uncharted Territory: Abacavir in HIV Treatment Unveils Rare Side Effect - A Focus on Hypophosphatemia

Abstract PO3-12-05: Patient (pt)-provider communication challenges about side effects/toxicities from metastatic breast cancer (mBC) treatments

Abstract Introduction: Treatment decisions for ER+/HER2- mBC may be influenced by pt knowledge about treatment side effects, which is shaped by pt-provider communication. We conducted a survey of pts with ER+/HER2- mBC to better understand pt expectations and experiences of treatment toxicities, the extent they were discussed by the pts’ medical team (MT), and the sources/types of side effect information pts prefer. Methods: The 55-question, online ESR1 QUAlity of Life Survey 3 (EQUALS 3) survey was emailed to US pts from the Cure Media Group and authors’ contacts, and posted to private BC Facebook and Twitter pt groups for 2 weeks in June 2023. Eligible pts had ER+/HER2- mBC and reported changing treatments due to progression. Pts received a $10 gift card at survey completion. Survey answers were descriptively summarized. Results: 213 pts completed the survey; they were < 60 yrs of age (77%), White (44%) or Hispanic/Latino (48%), peri-/postmenopausal (54%), and urban-area residents (51%); and had college education (71%) and household income >$50K (66%). Most pts were on 2nd (36%) or 3rd+ (51%) therapy lines. Current mBC treatments were endocrine therapy ± targeted agent (70%), antibody-drug conjugate (8%), chemotherapy (11%), and others (10%). Most pts’ oncologists were female (65%), BC specialists (51%), and from an academic hospital (61%). Only half (49%) of surveyed pts felt extremely/very comfortable discussing side effects with their MT. Although 86% felt well informed about treatment toxicities, MTs did not proactively ask about pts’ greatest concerns on side effects for 15% of pts, nor about what side effects pts would find tolerable or intolerable for 25%. Oncologist/MT inquired about acceptability of side effects most often with treatment change (25%) or when brought up by the pt (20%), and at every single visit for only 19% of pts. Most pts felt extremely prepared for treatment toxicities (78%) and well prepared to manage them (86%), but 19% of pts still felt that their MT did not provide optimal guidance on managing potential side effects. Pt-centered conversations were most often missing: what rare but serious side effects to expect (44%), how to deal with potential side effects (39%), and what common side effects to expect (32%). Pts also reported that the likelihood of experiencing side effects (40%), what rare but serious side effects to expect (39%), and how to deal with potential side effects (28%) were not well presented. To facilitate treatment decisions, pts would like more time discussing treatment options (48%) or side effects (39%); additional written or visual resources on side effects (29%, 23%, respectively) or efficacy (39%, 8%); and the ability to ask questions and receive meaningful answers (39%), talk to other pts (20%), or listen to videos of their stories (11%). Pt testimonials (45%), toxicity descriptions/examples (42%), and toxicity management strategies (36%) were the most common additional forms of information that pts would like to have had on side effects. Conclusion: In this survey of pts with ER+/HER2- mBC, not all pts were comfortable discussing treatment toxicities with their MT, but MTs are mostly addressing side effects. However, there is still room for communication improvement and additional forms of toxicity information are needed for optimal decision-making. Despite generally feeling well prepared for toxicities, a significant proportion of pts report that the range and specifics of side effects and how to manage them were missing or not well presented in MT discussions. This survey highlights the need to improve both provider and pt education with the goal of effectively communicating toxicity specifics of mBC therapies, as well as the need for standardized pt education tools detailing risks and benefits of mBC therapies to assist pts in shared decision-making conversations. Citation Format: Sarah Sammons, Jane Meisel, Timothy Pluard, Kelly Shanahan, Fumiko Chino, Dario Trapani, Dominic Carroll, Monica Kozlowski, Elizabeth Attias, Nicole Kuderer. Patient (pt)-provider communication challenges about side effects/toxicities from metastatic breast cancer (mBC) treatments [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-12-05.

Serpentine supravenous hyperpigmentation (SSH) in nasopharyngeal carcinoma patient on docetaxel and carboplatin chemotherapy: a case report

Serpentine supravenous hyperpigmentation (SSH) is a rare but unique side effect of intravenous anticancer. It manifests as linear hyperpigmentation eruption on the skin that radiates along the superficial vein accompanied by mild pain and/or itch. This SSH does not cause systemic alterations, however, most patients complained about its cosmetic effects. The diagnosis of SSH can be made clinically, although histopathological examinations can aid in excluding differential diagnoses. We reported a case of SSH found in a nasopharyngeal cancer patient during docetaxel and carboplatin chemotherapy. It is a potentially alarming interface dermatitis that is not lot reported in the literature. It was reported, the patient tolerated the second and third cycles well with less severe side effects when premedicated with 250 mL NaCl 0.9% bolus intravenously before and after chemotherapy sessions, 10 mg cetirizine every 24 hr orally, and desoximetasone cream 0.25% every 12 hr topically added.

A Paralyzing Consequence: Succinylcholine-Induced Hyperkalemia, a Rare but Dangerous Side Effect

A Paralyzing Consequence: Succinylcholine-Induced Hyperkalemia, a Rare but Dangerous Side Effect

Large Vessel Vasculitis in a Patient Receiving G-CSF: A Possible Differential for Fever of Unknown Origin.

Large vessel vasculitis is a known but rare side effect of granulocyte colony-stimulating factor (G-CSF) therapy. We report a case of adenocarcinoma lung with pleural infiltration and mediastinal lymphadenopathy, who was treated with neoadjuvant chemotherapy and pegylated G-CSF. After three cycles, he developed a fever. He underwent F-18 fludeoxyglucose (FDG) positron emission tomography computed tomography for fever of unkwnown origin evaluation, which revealed a response to chemotherapy along with the appearance of FDG avid mural thickening in a few large arteries, suggesting a diagnosis of G-CSF-induced large vessel vasculitis.

Association of PARP inhibitor treatment on the prevalence and progression of clonal hematopoiesis in patients with advanced prostate cancer.

Poly ADP-ribose polymerase (PARP) inhibitors are approved for the treatment of some men with advanced prostate cancer. Rare but serious side effects include myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). The impact of PARP inhibitors on clonal hematopoiesis (CH), a potential precursor lesion associated with MDS and AML, is incompletely understood in prostate cancer. We hypothesized that PARP inhibitors would increase CH prevalence and abundance. We prospectively enrolled participants with advanced prostate cancer treated with PARP inhibitors. The presence of CH was assessed from leukocytes using an ultra-deep error-corrected dual unique molecular identifiers sequencing method targeting 49 genes most commonly mutated in CH and myeloid malignancies. Variant allele frequencies (VAF) of ≥0.5% were considered clinically significant. Blood samples were collected before and after PARP inhibitor treatment. Ten men were enrolled; mean age of 67 years. Six patients had Gleason 7 disease, and four had Gleason ≥8 disease at diagnosis. Nine had localized disease at diagnosis, and eight had prior treatment with radiation. The mean time between pre- and post-treatment blood samples was 11 months (range 2.6-31 months). Six patients (60%) had CH identified prior to PARP inhibitor treatment, three with multiple clones. Of 11 CH clones identified in follow-up, 5 (45%) appeared or increased after treatment. DNMT3A, TET2, and PPM1D were the most common CH alterations observed. The largest post-treatment increase involved the PPM1D gene. CH alterations are frequently found after treatment with PARP inhibitors in patients with prostate cancer and this may be one mechanism by which PARP inhibitors lead to increased risk of MDS/AML.

Structural Characterization of a Pathogenic Antibody Underlying Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT).

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare but dangerous side effect of adenoviral-vectored COVID-19 vaccines. VITT had been linked to production of autoantibodies recognizing platelet factor 4 (PF4). Here, we characterize anti-PF4 antibodies obtained from a VITT patient's blood. Intact mass measurements indicate that a significant fraction of these antibodies represent a limited number of clones. MS analysis of large antibody fragments (the light chain and the Fc/2 and Fd fragments of the heavy chain) confirms the monoclonal nature of this component of the anti-PF4 antibodies repertoire and reveals the presence of a mature complex biantennary N-glycan within the Fd segment. Peptide mapping using two complementary proteases and LC-MS/MS was used to determine the amino acid sequence of the entire light chain and over 98% of the heavy chain (excluding a short N-terminal segment). The sequence analysis allows the monoclonal antibody to be assigned to the IgG2 subclass and verifies that the light chain belongs to the λ-type. Incorporation of enzymatic de-N-glycosylation into the peptide mapping routine allows the N-glycan in the Fab region of the antibody to be localized to the framework 3 region of the VH domain. This novel N-glycosylation site is the result of a single mutation within the germline sequence. Peptide mapping also provides information on lower-abundance (polyclonal) components of the anti-PF4 antibody ensemble, revealing the presence of all four subclasses (IgG1-IgG4) and both types of the light chain (λ and κ). This case study demonstrates the power of combining the intact, middle-down, and bottom-up MS approaches for meaningful characterization of ultralow quantities of pathogenic antibodies extracted directly from patients' blood.

A Case of Pemrolizumab-Associated Severe Gastritis Treated with Mycophenolate Mofetil

Immune checkpoint inhibitors have become a frequently used treatment in oncology practice. Although it has approved indications in many types of cancer, phase studies are ongoing in many types of cancer. Side effects due to the increasing use of immune checkpoint inhibitors have begun to be seen frequently. Cases of colitis, pancreatitis and hepatitis due to immune check point inhibitors have been reported very frequently; However, the number of gastritis cases is limited. Here, we presented a case of severe gastritis due to pembrolizumab in a patient with cholangiocellular carcinoma. When side effects develop due to immune check point inhibitors, infliximab and mycophenolate mofetil (MMF) treatments are used in steroid-refractory patients. In our patient, MMF treatment was started due to possible infectious processes due to a recent attack of cholangitis and the inability to remove the stones in the common bile duct. Response to MMF treatment was obtained after 3 months. We would like to state that MMF treatment is an option in cases that develop due to immune check point inhibitors. MMF treatment was used in a case of severe gastritis due to pembrolizumab, as it did not respond to steroid treatments. The patient responded after MMF treatment. We planned to present this rare side effect of pembrolizumab and the treatment strategies we applied in the development of side effects.

Tongue edema as an adverse drug reaction to low-dose olanzapine in a cancer patient receiving palliative care.

Olanzapine is an atypical neuroleptic indicated for treatment of various psychiatric disorders, but it has also several indications in palliative care (PC) patients: opioids misuse, nausea not related to chemotherapy, anorexia-cachexia syndrome, and sleep and mood disorders. Peripheral and facial edema are a rare side effect of the treatment with olanzapine. I report a case of an advanced cancer patient cared receiving PC who developed moderate tongue edema on day 1 of a low dose of olanzapine. A patient with advance and metastatic colon cancer presented moderate tongue edema on day 1 of a low dose (2.5 mg) of olanzapine for the treatment of his nausea, anorexia-cachexia syndrome, and mood disorder (mainly anxiety). The patient discontinued the drug with resolution of the edema. The day after he called our outpatients' service, a prompt physical examination, together with blood tests, excluded other differential diagnosis. To the best of our knowledge, this is the second case reporting head and neck localized edema due to olanzapine treatment in a patient with advanced cancer receiving PC. Considering the increasing use of olanzapine as off-label treatment in these patients (often for cluster symptoms), our report could help clinicians in daily practice and researchers on put a deeper focus on indications for olanzapine in PC.

Self-induced Anuria with Diclofenac: An Interesting Case of “Quadruple Whammy” Acute Kidney Injury

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) are a group of drugs widely prescribed and used worldwide. Patients taking NSAIDs, including diclofenac, should be aware of its potential nephrotoxic effects. However, the rapid onset of acute kidney injury (AKI) after a single dose of diclofenac is considered a very rare side effect. Case Presentation: We present a 66-year-old woman with habitual self-induced anuria with the chief complaint of shoulder pain due to falling down. The patient presented with various co-morbid conditions, including hypertension, type 2 diabetes, tricuspid valve repair, and aortic valve replacement. She rapidly developed anuria after receiving a single dose of diclofenac over the previous two days of admission. Creatinine and BUN exhibited a significant rise in laboratory tests. During hospitalization, the consumption of NSAIDs was prohibited and losartan and furosemide were discontinued. Moreover, phenacetin was used to relieve pain instead. Luckily, after two days of hospitalization, urine output returned to normal levels. Additionally, creatinine and BUN levels gradually decreased to baseline values. Conclusion: To the best of our knowledge, we described a rare case of diclofenac-induced AKI presenting with anuria, a complete cessation of urine flow, in a patient with no previous kidney complications. This case can be explained by the phenomenon known as “quadruple Whammy,” which involves the concurrent use of NSAIDs, ARBs, and diuretics in the setting of hypovolemia.

Risperidone Induced DRESS Syndrome: A case report

IntroductionDRESS (Drug Reaction with Eoshinophilia and Systemic Symptoms) syndrome, also called DIHS (Drug-Induced Hypersensitivity Syndrome) is a rare drug-induced systemic hypersensitivity reaction that can be potentially life-threatening (Choudhary et al. J Clin Aesthet Dermatol 2013; 6 -7). Risperidone is an antipsychotic drug with significant antagonist activity at the 5-HT2 and the D2 receptors. It has been reported that risperidone may be effective in controlling agitation, delusion, hallucination, and withdrawal behavior in geriatric patients (Yunusa & El Helou. Front Pharmacol 2020;11:596).Objectives The aim of this study is to demonstrate the case of developed DRESS syndrome following the use of risperidone.Methods The 81-year-old female patient was admitted to the Dermatology Clinic due to skin rash, high fever and leukocytosis following the use of risperidone. The patient was consulted to Psychiatry.Results In her history it was determined that risperidone 0.5 mg/d was started to the patient with depression due to agitative symptom. On the 4th day of treatment, targeoid lesions, starting from the back and spreading first to the trunk and then to the extremities, were observed. Further laboratory examinations revealed that the fever was measured at 39.5 C°, liver enzymes were elevated (ALT= 119 IU/ lt, AST= 124 IU /lt), and significant leukocytosis (WBC =12.000) was present along with the lesions. The patient was planned to be hospitalized to Dermatology Clinic on the 5th day and risperidone was stopped. The patient’s agitation increased and following the risperidone discontinuation thereupon the lesions tended to fade and desquamation began. After the treatment of the DRESS syndrome, aripiprazole was given to the patient for agitative symptom. The level of agitation symptoms decreased, and the patient tolerated aripiprazole well without any observed side effects.Image:ConclusionsWhen initiating medication for the elderly population to address agitation, considering such rare side effects can prevent the patient from being hospitalized due to DRESS syndrome. To the best of our knowledge, this is the first case report associated with DRESS syndrome and risperidone treatment thus, it is necessary to be very careful when starting psychotropic medication for elderly patients.Disclosure of InterestNone Declared

Validation of alopecia coding in US claims data among women of childbearing age.

Accurately identifying alopecia in claims data is important to study this rare medication side effect. To develop and validate a claims-based algorithm to identify alopecia in women of childbearing age. We linked electronic health records from a large healthcare system in Massachusetts (Mass General Brigham) with Medicaid claims data from 2016 through 2018 to identify all women aged 18 to 50 years with an ICD-10 code for alopecia, including alopecia areata, androgenic alopecia, non-scarring alopecia, or cicatricial alopecia, from a visit to the MGB system. Using eight predefined algorithms to identify alopecia in Medicaid claims data, we randomly selected 300 women for whom we reviewed their charts to validate the alopecia diagnosis. Positive predictive values (PPVs) were computed for the primary algorithm and seven algorithm variations, stratified by race. Out of 300 patients with at least 1 ICD-10 code for alopecia in the Medicaid claims, 286 had chart-confirmed alopecia (PPV = 95.3%). The algorithm requiring two diagnosis codes plus one prescription claim for alopecia treatment identified 55 patients (PPV = 100%). The algorithm requiring 1 diagnosis code for alopecia plus 1 procedure claim for intralesional triamcinolone injection identified 35 patients (PPV = 100%). Across all 8 algorithms tested, the PPV varied between 95.3% and 100%. The PPV for alopecia ranged from 94% to 100% in White and 96%-100% in 48 non-White women. The exact date of alopecia onset was difficult to determine in charts. At least one recorded ICD-10 code for alopecia in claims data identified alopecia in women of childbearing age with high accuracy.

Severe Hyperhidrosis Secondary to Bupropion Use and Treatment. A case report.

IntroductionHyperhidrosis, the excessive and uncontrollable sweating, is a well-documented side effect of various medications. Among these, bupropion, a commonly prescribed antidepressant and smoking cessation aid, has been associated with the development of severe hyperhidrosis in a subset of patients. This clinical report aims to shed light on a compelling case of severe hyperhidrosis induced by bupropion use and the subsequent treatment strategies employedThe patient under discussion is a 42-year-old female with a history of recurrent major depressive disorder and a previous favorable response to selective serotonin reuptake inhibitors (SSRIs). Due to side effect concerns and a desire to quit smoking, she was transitioned to bupropion, a norepinephrine-dopamine reuptake inhibitor (NDRI), at a standard therapeutic dose of 150 mg daily.Approximately four weeks after initiating bupropion therapy, the patient began experiencing debilitating symptoms of excessive sweating, particularly affecting her palms, soles, and axillae. The profuse sweating episodes occurred throughout the day and night, significantly impairing her quality of life, social interactions, and occupational functioning. No previous history of hyperhidrosis was reported, and physical examinations revealed no underlying medical conditions or dermatological issues.ObjectivesTo aknowledge the importance of recognizing and addressing medication-induced side effects within the realm of psychiatry and an early implementation of patient-centered treatment.MethodsClinical case report and a brief literature review.ResultsThe treatment of hyperhidrosis secondary to bupropion use presents a challenging clinical scenario that requires a delicate balance between managing the distressing side effect and ensuring the continued efficacy of psychiatric therapy. Given the rarity of severe hyperhidrosis as a side effect of bupropion, there is a limited body of evidence guiding treatment strategies. Gradual withdrawal in the dose of bupropion was initiated, with careful monitoring of depressive symptoms to prevent relapse, switching to Duloxetine 90mg daily, with adecuate efectiveness.In this particular case, the combination of medication adjustment and psychological support led to a significant reduction in hyperhidrosis symptoms. The patient reported improved social interactions, enhanced self-esteem, and restored occupational functioning. Importantly, her depressive symptoms remained well-managed, underscoring the success of the treatment strategy.ConclusionsThis clinical report highlights the importance of a patient-centered approach when addressing rare medication-induced side effects within the field of psychiatry. Bupropion withdrawal and regular follow-up showed effective in the treatment of the simptoms. Future research may provide additional insights and treatment options for cases like this, further enhancing patient care and outcomes.Disclosure of InterestNone Declared