Recurrent strokes and memory loss in a patient with triple-positive antiphospholipid antibody syndrome.

Antiphospholipid syndrome may cause recurrent thromboembolic events of the microvasculature, arteries and veins. It is also characterised by a range of neurological and psychiatric dysfunctions, as well as complications during pregnancy. Patients with triple-positive antiphospholipid syndrome have persistently elevated levels of lupus anticoagulant (LA), anti-beta-2-glycoprotein I (B2GPI) and anticardiolipin antibodies (aCL). These patients also have a higher risk of initial or recurrent thrombosis.We report the case of a 36-year-old man who was presented with progressive memory loss and recurrent stroke. He had persistently elevated antiphospholipid antibody titres (LA, aCL-immunoglobulin G and B2GPI antibodies). These features persisted while the patient was receiving low-dose aspirin (LDA), 81mg daily. Vitamin K antagonist (VKA); warfarin, with the international normalised ratio (INR) maintained at 2-3 was then added to his treatment regimen. The VKA dose was maintained at - a higher therapeutic INR while LDA administration was continued to achieve resolution of the patient's symptoms.

IgG4-Related Disease With Renal and Pulmonary Involvement.

Immunoglobulin G4-related disease (IgG4-RD) is a rare immune-mediated disease affecting multiple organs and tissues. There is often the presence of elevated serum Ig4 subtype with histological evidence of lymphoplasmacytic infiltration, fibrosis, and phlebitis. The mainstay of treatment is steroids therapy. We report the case of a 66-year-old man presenting with acute on chronic renal failure and pulmonary nodules seen on PET-CT scan. He also had elevated serum IgG4 subclass and histological features in keeping with IgG4-RD. He failed steroid therapy but responded subsequently to rituximab with complete resolution of his symptoms.

Acute stress cardiomyopathy following treatment of status asthmaticus.

Broken heart syndrome, otherwise known as takotsubo syndrome, is stress-induced cardiomyopathy. Clinical presentation mimics acute ST segment elevation myocardial infarction, but with characteristic left ventricular apical ballooning. The mechanism is linked to overstimulation of the sympathetic system from high circulating catecholamine levels. We report a 46-year-old Caucasian female whose treatment of status asthmaticus with ketamine and epinephrine precipitated this syndrome. She required hemodynamic support with an intra-aortic balloon pump and dobutamine infusion. Myocardial function improved dramatically with supportive treatment. Iatrogenically induced takotsubo syndrome with vasoactive agents should be suspected in acute left ventricular dysfunction without coronary artery disease.

G-CSF-Associated Bone Marrow Necrosis in AML after Induction Chemotherapy.

Bone marrow necrosis (BMN) is defined as necrosis of the myeloid tissues and stroma without involvement of the cortical bone. We report a case of 66-year-old male with AML-M4 (FAB classification) who was given induction chemotherapy with cytarabine and daunorubicin. Filgrastim at 480 micrograms was administered on days 15-19 to shorten the duration of neutropenia. Consequently patient developed severe pelvic bone pain, leukoerythroblastosis, and severe leukocytosis. Repeat bone marrow aspiration and biopsy on day 21 confirmed bone marrow necrosis. These manifestations responded quickly to discontinuation of filgrastim. Subsequently, he recovered full myelopoiesis. We suggest that there may be more cases of BMN associated with G-CSF that are undiagnosed.