Geriatric Pharmacotherapy Case Series: Recurrent Angioedema Following Discontinuation of ACE Inhibitor Therapy.

Introduction Angiotensin-converting enzyme inhibitors (ACEIs) are first-line pharmaceutical agents in common chronic conditions such as hypertension and heart failure with reduced ejection fraction. When angioedema occurs, if secondary to ACEIs, discontinuation of the ACEI is necessary to mitigate the risk of recurrent angioedema. While angioedema is a well-known adverse effect of ACEIs, it is not well-known that angioedema may recur even after ACEI discontinuation. Additionally, only few reports in the literature describe this phenomenon. This case describes an older man with a history of chronic obstructive pulmonary disease, hypothyroidism, diabetes mellitus, hypertension, and heart failure who presented from an assisted living facility with recurrent angioedema 12 days after an initial episode of angioedema where his ACEI therapy (enalapril) was discontinued. Assessment Empiric methylprednisolone, diphenhydramine, intramuscular epinephrine, intravenous C1 esterase inhibitor Berinert®, and two units of fresh frozen plasma was given in the emergency department. The patient was monitored in the intensive care unit because of mild airway compromise but did not require invasive airway protection. Serum C4 level was normal, ruling out hereditary angioedema. Outcome Patient was discharged after five days in stable condition with resolution of symptoms. Conclusion ACEIs are the most common cause of drug-induced angioedema in the United States. Angioedema is self-limiting swelling that requires close airway monitoring. While health professionals recognize the risk for angioedema with active ACEI use, it is not well known that the risk of angioedema may occur for months following cessation of ACEI therapy. Increased awareness of delayed ACEI-induced angioedema following ACEI discontinuation is important for both providers and pharmacists to provide appropriate diagnosis and monitoring. Improved awareness would also allow patients with a history of ACEI-induced angioedema to be cognizant of the potential for recurrence following drug discontinuation.

Drug Interactions Associated With Therapies for Pulmonary Arterial Hypertension.

Objective: To evaluate the potential for drug interactions with therapies for pulmonary arterial hypertension (PAH). Treatments include calcium channel blockers, phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, guanylate cyclase stimulators, prostacyclin analogues, and prostacyclin receptor agonists. Data Sources: A systemic literature search (January 1980-December 2021) was performed using PubMed and EBSCO to locate relevant articles. The mesh terms used included each specific medication available as well as "drug interactions." DAILYMED was used for product-specific drug interactions. Study Selection and Data Extraction: The search was conducted to identify drug interactions with PAH treatments. The search was limited to those articles studying human applications with PAH treatments and publications using the English language. Case reports, clinical trials, review articles, treatment guidelines, and package labeling were selected for inclusion. Data Synthesis: Primary literature and package labeling indicate that PAH treatments are subject to pharmacokinetic and pharmacodynamic interactions. The management of PAH is rapidly evolving. As more and more evidence becomes available for the use of combination therapy in PAH, the increasing use of combination therapy increases the risk of drug-drug interactions. Pulmonary arterial hypertension is also associated with other comorbidities that require concomitant pharmacotherapy. Conclusion: The available literature indicates that PAH therapies are associated with clinically significant drug interactions and the potential for subsequent adverse reactions. Clinicians in all practice settings should be mindful that increased awareness of drug interactions with PAH therapy will ensure optimal management and patient safety.

Role of procalcitonin as a predictor of clinical outcomes in hospitalized patients with COVID-19.

OBJECTIVES: In this study, we aimed to determine the correlation between procalcitonin (PCT) levels and clinical outcomes including in-hospital mortality, intensive care unit (ICU) length of stay, and hospital length of stay in patients hospitalized with COVID-19. METHODS: Clinical, laboratory, and demographic data of 223 patients who met inclusion criteria were analyzed. PCT measurements of 0.25 ng/mL and 0.50 ng/mL were used to stratify patients into 2 mutually exclusive groups. RESULTS: Patients with PCT above 0.25 ng/mL on admission had significantly elevated Acute Physiology and Chronic Health Evaluation II scores (9 vs 8; P = 0.042) and C-reactive proteins levels (111 µg/mL vs 79 µg/mL; P = 0.007). A multivariable binary logistic regression model demonstrated no relationship between PCT and mortality (OR = 1.00; 95% Cl: 0.97 to 1.02; P = 0.713). Kaplan-Meier analysis revealed no statistical evidence of a difference between PCT groups and hospital length of stay (P = 0.144 for 0.25 ng/mL, P = 0.368 for 0.50 ng/mL) or intensive care unit length of stay (P = 0.986 for 0.25 ng/mL, P = 0.771 for 0.50 ng/mL). CONCLUSIONS: Elevated PCT levels were associated with severity of illness but did not correlate with in-hospital mortality, hospital length of stay, or ICU length of stay.

Review of Cases of E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) and Brief Review of the Literature.

Since the appearance of the E-Cigarette in the early 2000s, its industry, popularity, and prevalence have risen dramatically. In the past, E-Cigarette use with the vaping of nicotine or cannabis products had been associated with a few reported cases of lung injury. However, in 2019, thousands of cases of E-Cigarette or vaping product use-associated lung injury (EVALI) were reported in the United States. Evidence linked this outbreak with vaping of tetrahydrocannabinol (THC). We report two confirmed cases of EVALI and their associated clinical, radiologic, and pathologic features. This report supports the growing body of information regarding EVALI. It also discusses various substances, particularly vitamin E acetate, which has been suggested as a causative agent.

Mimickers of chronic thromboembolic pulmonary hypertension on imaging tests: a review.

Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by mechanical obstruction of large pulmonary arteries secondary to one or more episodes of pulmonary embolism. Ventilation perfusion scan is the recommended initial screening test for this condition and typically shows multiple large mismatched perfusion defects. However, not all patients with an abnormal ventilation perfusion scan have CTEPH since there are other conditions that be associated with a positive ventilation perfusion scan. These conditions include in situ thrombosis, pulmonary artery sarcoma, fibrosing mediastinitis, pulmonary vasculitis and sarcoidosis, among others. Although these conditions cannot be distinguished from CTEPH using a ventilation perfusion scan, they have certain characteristic radiological features that can be demonstrated on other imaging techniques such as computed tomography scan and can help in differentiation of these conditions. In this review, we have summarized some key clinical and radiological features that can help differentiate CTEPH from the CTEPH mimics.

Treatment Discontinuation or Interruption in Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension (PAH) is a progressive disease, which can be potentially fatal. The management of a complex disease like PAH requires a multidisciplinary approach from a team consisting of physicians, nurses, social workers, and pharmacists. Adherence to PAH-specific therapy is one of the key factors in the management of this disease. Poor adherence to treatment is a common problem in PAH as it is in many chronic diseases. Management of medication interruptions is a challenge in patients with PAH that can lead to negative consequences. However, for most PAH-specific drugs, there are no clear guidelines on how to manage temporary or abrupt medication discontinuations. In this review, we summarized the available literature and provide suggestions on how to manage interruptions of PAH-specific therapies.

Radiation Exposure in the Medical ICU: Predictors and Characteristics.

BACKGROUND: Patients admitted to the medical ICU (MICU) are often subjected to multiple radiologic studies. We hypothesized that some endure radiation dose exposure (cumulative effective dose [CED]) in excess of annual US federal occupational health standard limits (CED ≥ 50 mSv) and 5-year cumulative limit (CED ≥ 100 mSv). We also evaluated the correlation of CED with Acute Physiology and Chronic Health Evaluation (APACHE) III score and other clinical variables. METHODS: Retrospective observational study conducted in an academic medical center involving all adult admissions (N = 4,155) to the MICU between January 2013 and December 2013. Radiation doses from ionizing radiologic studies were calculated from reference values to determine the CED. RESULTS: Three percent of admissions (n = 131) accrued CED ≥ 50 mSv (1% [n = 47] accrued CED ≥ 100 mSv). The median CED was 0.72 mSv (interquartile range, 0.02-5.23 mSv), with a range of 0.00 to 323 mSv. Higher APACHE III scores (P = .003), longer length of MICU stay (P < .0001), sepsis (P = .03), and gastrointestinal disorders and bleeding (P < .0001) predicted higher CED in a multivariable linear regression model. Patients with gastrointestinal bleeding and disorders had an odds ratio of 21.05 (95% CI, 13.54-32.72; P < .0001) and 6.94 (95% CI, 3.88-12.38; P < .0001), respectively, of accruing CED ≥ 50 mSv in a multivariable logistic regression model. CT scan and interventional radiology accounted for 49% and 38% of the total CED, respectively. CONCLUSIONS: Patients in the MICU are exposed to radiation doses that can be substantial, exceeding federal annual occupational limits, and in a select subset, are > 100 mSv. Efforts to justify, restrict, and optimize the use of radiologic resources when feasible are warranted.

Paraganglioma Presenting as Postpartum Fever of Unknown Origin.

A young healthy postpartum mother presented with intermittent high fevers and tachycardia. Appropriate testing was done to rule out infectious causes including pan cultures but no identifiable infectious source was found. A CT of the abdomen showed a retroperitoneal mass with two small pulmonary nodules and a bony metastatic lesion. She was found to have stage 4 extra-adrenal paraganglioma with metastases to the lungs and spine. She underwent resection of the mass and is currently undergoing palliative radiation to the spine for pain control. Subsequent genetic testing identified a likely pathogenic variant in SDHB, confirming a diagnosis of Hereditary Paraganglioma-Pheochromocytoma syndrome.

A 70-Year-Old Man With Large Cervical and Mediastinal Lymphadenopathies.

We present a case of a 70-year-old man with enlarged mediastinal and cervical lymph nodes that provided interesting radiologic and pathologic observations. The 70-year-old black man was found to have enlarged mediastinal lymph nodes. He had symptoms of atypical chest pain and generalized weakness for 2 weeks prior to the diagnosis. He denied shortness of breath, fever, chills, or night sweats. He was treated for hypertension and onychomycosis. Basic laboratory findings were within normal limits. Pulmonary function tests at the time of presentation showed FEV1, FVC, and FEV1/FVC ratio of 123% predicted, 133% predicted, and 0.7, respectively. Meanwhile, total lung capacity and carbon monoxide diffusing capacity were 103% and 107% predicted, respectively. Two weeks before he presented to our institution, the patient underwent bronchoscopy with transbronchial biopsies of the right lower lobe and endobronchial ultrasound-guided transbronchial needle aspiration of the right hilar lymph nodes.

A case of typhoid Fever with hepatic granulomas and enteritis.

The common histopathologic hepatic manifestations in patients infected with Salmonella include cloudy swelling and balloon degeneration with vacuolation of the hepatocytes and steatosis. Hepatic granulomas are a very rare finding, so far reported in very few cases. We report a 64-year-old patient with Salmonella enteritis who was found to have multiple 1.4 to 1.6 cm hypoechoic liver masses on ultrasound of the abdomen which on biopsy revealed hepatic granulomas. This case highlights the importance of keeping the differential diagnosis of Salmonella typhi (S. typhi) in mind in a patient with hepatic granulomas.

Prolonged zoledronic acid-induced hypocalcemia in hypercalcemia of malignancy.

Zoledronic acid is a parenteral long-acting bisphosphonate that has been shown to be more effective than other bisphosphonates in treating hypercalcemia of malignancy. It is important to be aware of its ability to induce prolonged and severe hypocalcemia (hypoCa) following administration, which can be difficult to control despite aggressive calcium replacement. We report on a patient with metastatic breast cancer who presented with severe symptomatic hypoCa after receiving zoledronic acid for hypercalcemia of malignancy.