ADAMTS13 deficiency and thrombotic thrombocytopenic purpura associated with trimethoprim-sulfamethoxazole.

Thrombotic thrombocytopenic purpura (TTP) is a hematological disease characterized by microangiopathic hemolytic anemia and thrombocytopenia. Although the link between ADAMTS13 deficiency and idiopathic TTP has been well-established, the role of trimethoprim-sulfamethoxazole (TMP-SMX) in the pathogenesis of TTP is not yet well elucidated. To the best of our knowledge, there have been only two previous reports linking this medication with the development of TTP. We present the case of a healthy woman, age 26 years, who developed TTP during TMP-SMX therapy for urinary tract infection. She was found to have ADAMTS13 deficiency with anti-ADAMTS13 antibodies. Her condition responded to discontinuation of the TMP-SMX, plasmapheresis, and rituximab therapy. We speculate that the acquired ADAMTS13 deficiency might have been triggered by the TMP-SMX therapy.

Association between blood glucose level and outcomes in patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Increased blood glucose is associated with adverse clinical outcomes among patients with major illnesses. This study examined the association between blood glucose and adverse outcomes among hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease, for which limited prior data were available. METHODS: We studied a cohort of 209 hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease. Univariate analyses and multivariate logistic regression analyses with backward elimination method were performed to evaluate factors associated with in-hospital complications, length of hospitalization, 30-day hospital readmission, and 90-day all-cause mortality. RESULTS: Multivariate logistic regression analysis with backward elimination method revealed that lower blood glucose and age at hospital admission were the most significant risk factors for in-hospital complication. Received respiratory support and in-hospital complications were the most significant risk factors for the length of hospitalization. There were no significant risk factors associated with 30-day hospital readmission and 90-day all-cause mortality. CONCLUSION: The analyses failed to reveal significant associations between higher blood glucose levels and adverse outcomes. We showed that lower glucose levels (hypoglycemia) results in higher risk for in-hospital complications. In-hospital complications results in longer length of hospitalization, which implies that lower glucose levels (hypoglycemia) indirectly may result in longer length of hospitalization. More studies are needed to better clarify the cause for these associations.

Non-cardiogenic pulmonary edema complicating electroconvulsive therapy: short review of the pathophysiology and diagnostic approach.

Acute pulmonary edema complicating electroconvulsive therapy is an extremely uncommon event that has rarely been described in the literature. Different theories, including one suggesting a cardiogenic component, have been proposed to explain its genesis. The present report describes a classic presentation of this condition with review of its potential mechanisms and diagnostic approach. After successful completion of a session of electroconvulsive therapy, a 42-year-old woman with major depressive disorder developed acute systemic high blood pressure, shortness of breath, and hemoptysis. A chest radiograph demonstrated diffuse bilateral pulmonary infiltrates. Initially cardiogenic pulmonary edema was presumed, but an extensive diagnostic work-up demonstrated normal systolic and diastolic left ventricular function, and with only supportive measures, a complete clinical and radiographic recovery was achieved within 48 hours. The present case does not support any cardiogenic mechanism in the genesis of this condition.

Apical hypertrophic cardiomyopathy presenting as recurrent unexplained syncope.

Apical hypertrophic cardiomyopathy (AHC) is a rare variant of hypertrophic cardiomyopathy. Since its description by Sakamoto in 1976 in Japanese patients, our understanding of this entity has evolved. Although cardiac magnetic resonance imaging has emerged as the gold standard for diagnosing AHC, clinical attention must be drawn to the unique electrocardiographic features that provide the initial clues to making the diagnosis. In this case, we present a 47-year-old man with AHC who presented with recurrent syncope, but anomalies on his electrocardiogram went unnoticed on two clinical encounters. He was subsequently admitted to our service and rapidly diagnosed after we observed the very classical findings in the plain twelve lead electrocardiogram done at the time of admission. In a clinical encounter involving a patient presenting with recurrent syncope, special attention must be focused on the electrocardiogram to decipher the unique diagnostic features it might show.

Brain abscesses complicating acute pneumococcal meningitis during etanercept therapy.

Brain abscess formation as a sequelae of community-acquired pneumococcal meningitis is extremely rare, accounting for less than 1% of all meningitis complications. Although metastatic seeding from a distal peripheral septic focus has been observed, this phenomenon most commonly occurs in the context of ear, nose and throat infections, post-cranial neurosurgical procedures, traumatic open cranial injury, or immunosuppression. We present the case of a man, 61 years old, on etanercept therapy for ankylosing spondylitis who developed multiple brain abscesses as a complication of pneumococcal meningitis. We believe that the predisposition to this extremely rare complication of a particularly aggressive pneumococcal meningitis was most likely due to the underlying immunosuppression resulting from etanercept therapy. As far as we know, this case is the first report linking multiple brain abscess formation in a patient with community-acquired pneumococcal meningitis with etanercept therapy.

Multilocular thymic cyst with epithelioid granulomata of unknown etiology: a radiologic and histopathologic correlation.

Thymic cysts (congenital or acquired) are believed to account for 3% to 5% of all mediastinal masses. Multilocular thymic cysts are an acquired reactive inflammatory process arising within the thymus gland and are less common than the congenital unilocular type. Multilocular cysts have been reported in association with a variety of neoplastic, autoimmune, and infectious conditions. We report a case of a 23-year-old white man who presented with a 2-week history of progressive right-sided shoulder and chest pain. He was found to have an anterior mediastinal mass involving the thymus. This case of multilocular thymic cyst is particularly unique due to the presence of abundant epithelioid granulomata within the cyst, a finding that has not previously been emphasized as a histologic feature of these lesions, and one that expands the histopathologic differential diagnosis, warranting exclusion of infectious and autoimmune etiologies.

Acute transient sensorineural hearing loss due to Anaplasma phagocytophilum.

We report the case of a patient who presented with a 3-month history of random epistaxis and recent onset of acute hearing loss associated with fever, chills, and myalgias. Pure tone audiometry revealed bilateral sensorineural hearing loss. Complete blood cell count showed an abnormal neutrophil count of 700/uL (normal >1900/microL) and platelet count of 25 x 10(3)/microL (normal >175 x 10(3)/microL). Giemsa-stained peripheral blood smear revealed neutrophilic intracytoplasmic inclusion consistent with anaplasma morulae. Polymerase chain reaction confirmed Anaplasma phagocytophilum. The patient was treated with oral doxycycline, and, after 14 days of treatment, the hearing loss had improved markedly. Therefore, we concluded that the patient's acute transient bilateral sensorineural hearing loss was associated with anaplasmosis.

Tako-tsubo cardiomyopathy in a patient with advanced colorectal adenocarcinoma.

Transient left ventricular dysfunction syndrome (TLVDS), or Tako-Tsubo cardiomyopathy (TC), is a clinical entity in which patients present with features of acute coronary syndrome, electrocardiogram abnormalities, and transient left ventricular (apical or mid-ventricular) dysfunction. Patients usually recover from this condition four to six weeks after the event. The etiology or triggering factors of TC remains unknown. Various triggering factors have been associated with this syndrome, with one of the most recent being malignancies. In this case report we present a postmenopausal female with underlying advanced malignancy who presented with TC. This is consistent with a recent hypothesis that in addition to currently known triggering factors, malignancies might well trigger TC in the context of a stressor or paraneoplastic phenomenon.