Thrombotic microangiopathy associated with synthetic cannabinoid receptor agonists.

Marijuana is one of the most commonly used recreational drugs in the United States. As marijuana is illegal in the majority of countries, the use of readily available and unregulated synthetic cannabinoids (SCBs) has increased. Little is known about the potential adverse effects of SCBs especially in regards to their nephrotoxicity. Case reports of acute kidney injury (AKI) from acute tubular injury secondary to their use have been reported. However, the exact pathology, mechanism, and extent of renal injury remain unknown. We report the first case of biopsy proven thrombotic microangiopathy (TMA) associated with SCBs resulting in AKI. The patient suffered significant morbidity with loss of renal function eventually requiring renal replacement therapy.

Autoimmune hemolytic anemia associated with babesiosis.

BACKGROUND: Babesiosis is endemic in selected areas in North America. Babesia infection is commonly associated with anemia, thrombocytopenia, hyponatremia and elevated liver enzymes. Autoimmune hemolytic anemia (AIHA) is known to be caused by parasitic and viral infections but has not been well characterized. CASE PRESENTATION: We describe two cases diagnosed with babesiosis triggering severe AIHA. One case had history of splenectomy, and the other was an elderly patient. Older, immunocompromised and asplenic patients may be particularly at risk for post-babesiosis AIHA (PB-AIHA). CONCLUSIONS: The pathogenesis for conventional AIHA and PB-AIHA appears to be different, since splenectomy is a treatment for conventional AIHA, whereas PB-AIHA is seen more often in asplenic patients. Further investigation into this intriguing mechanism of host immune response to babesiosis may help to elucidate the overall mechanism of infection- triggered AIHA.

Babesiosis-associated immune thrombocytopenia.

Thrombocytopenia is a common feature of babesiosis. The mechanism for thrombocytopenia in babesiosis remains elusive. We report a case of babesiosis with severe new onset immune thrombocytopenia (ITP). In addition to antibiotics treatment for babesiosis, ITP therapy was administered. ITP in the present case was most likely triggered by the babesia infection. The severity of ITP in this case was not proportional to the severity of parasitemia. The neoantigen triggering the autoimmune response in babesiosis requires further characterization.

Measuring spatial variation in secondary production and food quality using a common consumer approach in Lake Erie.

Lake Erie is a large lake straddling the border of the USA and Canada that has become increasingly eutrophic in recent years. Eutrophication is particularly focused in the shallow western basin. The western basin of Lake Erie is hydrodynamically similar to a large estuary, with riverine inputs from the Detroit and Maumee Rivers mixing together and creating gradients in chemical and physical conditions. This study was driven by two questions: (1) How does secondary production and food quality for consumers vary across this large mixing zone? and (2) Are there correlations between cyanobacterial abundance and secondary production or food quality for consumers? Measuring spatial and temporal variation in secondary production and food quality is difficult for a variety of logistical reasons, so here a common consumer approach was used. In a common consumer approach, individuals of a single species are raised under similar conditions until placed in the field across environmental gradients of interest. After some period of exposure, the response of that common consumer is measured to provide an index of spatial variation in conditions. Here, a freshwater mussel (Lampsilis siliquoidea) was deployed at 32 locations that spanned habitat types and a gradient in cyanobacterial abundance in the western basin of Lake Erie to measure spatial variation in growth (an index of secondary production) and fatty acid (FA) content (an index of food quality). We found secondary production was highest within the Maumee river mouth and lowest in the open waters of the lake. Mussel tissues in the Maumee river mouth also included more eicosapentaenoic and docosapentaenoic fatty acids (EPA and DPA, respectively), but fewer bacterial FAs, suggesting more algae at the base of the food web in the Maumee river mouth compared to open lake sites. The satellite-derived estimate of cyanobacterial abundance was not correlated to secondary production, but was positively related to EPA and DPA content in the mussels, suggesting more of these important FAs in locations with more cyanobacteria. These results suggest that growth of secondary consumers and the availability of important fatty acids in the western basin are centered on the Maumee river mouth.

The Conundrum of "Warfarin Hypersensitivity": Prolonged Partial Thromboplastin Time From Factor IX Propeptide Mutation.

Carboxylation of glutamic acid residues of vitamin K dependent clotting factors (II, VII, IX, and X) is essential to their biological functioning. Binding of these factors to γ-glutamyl carboxylase enzyme for carboxylation reaction is mediated by wild-type propeptide, a small sequence of amino acids that precede the actual polypeptide. Missense mutations at certain residue severely decrease the affinity of mutated propeptide for the enzyme. Such mutations are reported to occur at codon-10 of factor IX propeptide, a clinically silent metabolic event in normal conditions. However in the presence of warfarin, such mutations and resultant decrease affinity of factor IX propeptide for the enzyme that causes severe selective decrease in factor IX activity. This can potentially leads to life-threatening bleeding complications and known as one of the causes of warfarin hypersensitivity. It is imperative to recognize such cases early on to avoid additional warfarin therapy. Recurrent bleeding episodes, subtherapeutic to therapeutic range international normalized ratio values with relatively prolong partial thromboplastin time should raise the suspicion of underlying factor IX propeptide mutations.

Fatty acid composition at the base of aquatic food webs is influenced by habitat type and watershed land use.

Spatial variation in food resources strongly influences many aspects of aquatic consumer ecology. Although large-scale controls over spatial variation in many aspects of food resources are well known, others have received little study. Here we investigated variation in the fatty acid (FA) composition of seston and primary consumers within (i.e., among habitats) and among tributary systems of Lake Michigan, USA. FA composition of food is important because all metazoans require certain FAs for proper growth and development that cannot be produced de novo, including many polyunsaturated fatty acids (PUFAs). Here we sampled three habitat types (river, rivermouth and nearshore zone) in 11 tributaries of Lake Michigan to assess the amount of FA in seston and primary consumers of seston. We hypothesize that among-system and among-habitat variation in FAs at the base of food webs would be related to algal production, which in turn is influenced by three land cover characteristics: 1) combined agriculture and urban lands (an indication of anthropogenic nutrient inputs that fuel algal production), 2) the proportion of surface waters (an indication of water residence times that allow algal producers to accumulate) and 3) the extent of riparian forested buffers (an indication of stream shading that reduces algal production). Of these three land cover characteristics, only intense land use appeared to strongly related to seston and consumer FA and this effect was only strong in rivermouth and nearshore lake sites. River seston and consumer FA composition was highly variable, but that variation does not appear to be driven by the watershed land cover characteristics investigated here. Whether the spatial variation in FA content at the base of these food webs significantly influences the production of economically important species higher in the food web should be a focus of future research.

Rivermouth alteration of agricultural impacts on consumer tissue δ(15)N.

Terrestrial agricultural activities strongly influence riverine nitrogen (N) dynamics, which is reflected in the δ(15)N of riverine consumer tissues. However, processes within aquatic ecosystems also influence consumer tissue δ(15)N. As aquatic processes become more important terrestrial inputs may become a weaker predictor of consumer tissue δ(15)N. In a previous study, this terrestrial-consumer tissue δ(15)N connection was very strong at river sites, but was disrupted by processes occurring in rivermouths (the 'rivermouth effect'). This suggested that watershed indicators of N loading might be accurate in riverine settings, but could be inaccurate when considering N loading to the nearshore of large lakes and oceans. In this study, the rivermouth effect was examined on twenty-five sites spread across the Laurentian Great Lakes. Relationships between agriculture and consumer tissue δ(15)N occurred in both upstream rivers and at the outlets where rivermouths connect to the nearshore zone, but agriculture explained less variation and had a weaker effect at the outlet. These results suggest that rivermouths may sometimes be significant sources or sinks of N, which would cause N loading estimates to the nearshore zone that are typically made at discharge gages further upstream to be inaccurate. Identifying definitively the controls over the rivermouth effect on N loading (and other nutrients) will require integration of biogeochemical and hydrologic models.

Hypersensitivity to plasma exchange in a patient with thrombotic thrombocytopenic purpura.

To a limited extent, thrombotic thrombocytopenic purpura (TTP) in addition to its clinical features is being defined nowadays with laboratory tests such as the assay for the Von Willebrand factor-cleaving protease (ADAMTS 13) and its antibody. We present a case report of a patient with TTP and idiopathic thrombocytopenic purpura (ITP) who had an elevated inhibitor level after plasma exchange. After instituting plasma exchange, patient improved clinically with a platelet count in the normal range. Subsequently, she developed an elevated ADAMTS antibody titer accompanied by a decline in platelet count despite continued exchange. She was successfully treated with a combination of steroids, rituximab and increased dose plasmapheresis. Based on this experience, we conclude that a drop in platelet count while patient is undergoing plasma exchange especially in an initial episode of TTP needs prompt institution of additional therapy to improve outcomes. This case also brings to attention the possibility of an underlying ITP in a patient with an initial diagnosis of TTP.

A prospective study of a hand-held ultrasound device in abdominal aortic aneurysm evaluation.

PURPOSE: Effective treatment of abdominal aortic aneurysm (AAA) requires both early detection and timely repair to reduce aneurysm-related mortality. The purpose of this prospective study was to evaluate the utility of a hand-held ultrasonography (US) device in AAA screening in a Veterans Affairs vascular surgical service. METHODS: During a 16-month period, patients with risk factors for AAA were evaluated in a blinded fashion with a hand-held US device performed by physicians. A conventional abdominal duplex US examination was also performed by a certified vascular ultrasonographer. Results of the hand-held US was compared with the conventional duplex US examination. RESULTS: A total of 104 patients were evaluated (97 men, mean age 67 +/- 6.3 years). The mean times for hand-held and conventional duplex US examinations were 5.3 +/- 3.2 minutes and 3.1 +/- 2.4 minutes (not significant), respectively. Using the conventional duplex US as a reference, the sensitivity and specificity of the hand-held device in detecting a AAA were 93% and 97%, respectively. The positive and negative predictive values of the hand-held device were 89% and 98%, respectively. The likelihood ratios of positive and negative tests of the hand-held US device examination were 82 and 0.14, respectively. The diagnostic accuracy of the hand-held US device as compared with the conventional duplex US was 98%. CONCLUSIONS: A hand-held portable US device is effective and accurate in AAA screening with results comparable to the conventional abdominal duplex examination. Moreover, hand-held portable US for AAA screening can be performed expeditiously during physical examination. It should be used as an extension in routine physical examination in vascular patients.

Two patients with heparin-induced thrombocytopenia followed by idiopathic (immune) thrombocytopenic purpura: case report.

Heparin-induced thrombocytopenia (HIT) and idiopathic thrombocytopenic purpura (ITP) are separate and well-recognized clinical syndromes, 10both having potential for disastrous outcomes. Sequential occurrence of these two diseases has not been reported in the literature. We report herein two patients who were initially diagnosed as having HIT but whose later clinical course was similar to ITP. Although dysfunction of immune system seems to play a role, the precise mechanisms for the development of these diseases are unclear. As both conditions have different natural histories and require different treatment modalities, it is important to recognize that these two diseases may be seen sequentially.