Cutaneous Small-Vessel Vasculitis Induced by Escitalopram: A Case-Based Brief Review of the Literature.

A 65-year-old male with multiple comorbidities and recently diagnosed with diabetic kidney disease developed upper and lower extremity rash following escitalopram initiation for his depressive mood. Clinical assessment and skin biopsy confirmed cutaneous small-vessel vasculitis (CSVV), prompting drug discontinuation and oral methylprednisolone therapy. The resolution of the rash was achieved within a week. This rare case of CSVV induced by escitalopram highlights the importance of timely recognition and management of drug-induced CSVV and adds to the limited literature on selective serotonin reuptake inhibitor-associated CSVV.

Neuroendocrine Breast Carcinoma: Interesting Images of an Underdiagnosed Entity.

Breast cancer is the most common type of cancer of the female gender. A rare subtype of breast cancer is the invasive breast carcinoma (IBC) with neuroendocrine (NE) differentiation. Its incident is believed to be 0.1% to 5% of all breast cancers. We report a rare case of a 66-year old woman who presented with an isolated nodule of the left breast. The patient underwent modified radical mastectomy. Pathology revealed invasive breast carcinoma with neuroendocrine differentiation. Invasive breast carcinoma is an extremely rare group of neoplasms, the exact frequency of which cannot be determined with current data. Therefore, it is necessary for future studies to focus on the pathophysiology of this subtype of breast cancer and on the potential therapeutic approaches.

Abiraterone-Induced Secondary Hypertension: Two Wrongs Don't Make a Right.

Abiraterone, an inhibitor of both 17α-hydroxylase and 17,20-lyase, is considered a novel, state-of-the-art, life-prolonging therapy in the urologists' arsenal when treating prostate cancer. Despite its efficacy, it is linked with an increased risk of cardiovascular adverse effects. Herein, we report a case in which the administration of abiraterone resulted in a full-blown syndrome of apparent mineralocorticoid excess despite the concomitant administration of prednisolone; that is, secondary hypertension, hypokalemia, metabolic alkalosis, as well as elevated levels of adrenocorticotropic hormone (ACTH).

Pharmaceutical Management of Secondary Hyperparathyroidism and the Role of Surgery: A 5-Year Retrospective Study.

Background and Objectives: Secondary hyperparathyroidism (SHPT) poses a common condition among patients with chronic kidney disease (CKD) due to the chronic stimulation of the parathyroid glands as a result of persistently low calcium levels. As a first option for medical treatment, vitamin D receptor analogs (VDRAs) and calcimimetic agents are generally used. Apart from cinacalcet, which is orally taken, in recent years, another calcimimetic agent, etelcalcetide, is being administered intravenously during dialysis. Materials and Methods: In a 5-year retrospective study between 2018 and 2023, 52 patients undergoing dialysis were studied. The aim of this study is to highlight the possible effects and/or benefits that intravenously administered calcimimetic agents have on CKD patients. A total of 34 patients (65.4%) received cinacalcet and etelcalcetide while parathormone (PTH) and calcium serum levels were monitored on a monthly basis. Results: A total of 29 out of 33 patients (87.9%) that received treatment with etelcalcetide showed a significant decrease in PTH levels, which rose up to 57% compared to the initial values. None of the included patients needed to undergo parathyroidectomy (PTx) due to either extremely high and persistent PTH levels or severe side effects of the medications. It is generally strongly advised that parathyroidectomies should be performed by an expert surgical team. In recent years, a significant decrease in parathyroidectomies has been recorded globally, a fact that is mainly linked to the constantly wider use of new calcimimetic agents. This decrease in parathyroidectomies has resulted in an important decrease in complications occurring in cervical surgeries (e.g., perioperative hemorrhage and nerve damage). Conslusions: Despite the fact that these surgical complications cannot be easily compared to the pharmaceutical side effects, the recorded decrease in parathyroidectomies is considered to be notable, especially in cases of relapse where a difficult reoperation would be considered based on previously published guidelines.

Tertiary hyperparathyroidism masking an atypical parathyroid tumor.

Atypical parathyroid tumors represent a group of parathyroid neoplasms of uncertain malignant potential. In view of preoperative diagnostic difficulties, suspicious features for malignancy may guide the surgeon to perform a radical surgical approach.

Frequency of Thyroid Microcarcinoma in Patients Who Underwent Total Thyroidectomy with Benign Indication-A 5-Year Retrospective Review.

Background and Objectives: Incidental thyroid cancers (ITCs) are often microcarcinomas. The most frequent histologic type is a papillary microcarcinoma. Papillary thyroid microcarcinomas are defined as papillary thyroid tumours measuring less than 10 mm at their greatest diameter. They are clinically occult and frequently diagnosed incidentally in histopathology reports after a thyroidectomy. The aim of this study is to evaluate the rate of papillary thyroid microcarcinomas (PTMC) in patients who were thyroidectomised with indications of benign disease. Materials and Methods: We retrospectively evaluated the histological incidence of PTMC in 431 consecutive patients who, in a 5 year period, underwent a thyroidectomy with benign indications. Patients with benign histology and with known or suspected malignancy were excluded. Results: Histopathology reports from 540 patients who underwent a total thyroidectomy in our department between 2016 and 2021 were reviewed. A total of 431 patients were thyroidectomised for presumed benign thyroid disease. A total of 395 patients had confirmed benign thyroid disease in the final histopathology, while 36 patients had incidental malignant lesions (33 PTMC-7.67%, one multifocal PTC without microcarcinomas-0.23%, two follicular thyroid carcinoma-0.46%). Out of the PTMC patients, 29 were female and four were male (7.2:1 female-male ratio). The mean age was 54.2 years old. A total of 24 out of 33 patients had multifocal lesions, 11 of which co-existed with macro PTC. Nine patients had unifocal lesions. A total of 21 of these patients were initially operated on for multinodular goitre (64%), while 13 were operated on for Hashimoto/Lymphocytic thyroiditis (36%). Conclusions: PTMC-often multifocal-is not an uncommon, incidental finding after thyroidectomy for benign thyroid lesions (7.67% in our series) and often co-exists with other incidental malignant lesions (8.35% in our series). The possibility of an underlying papillary microcarcinoma should be taken into account in the management of patients with benign-especially nodular-thyroid disease, and total thyroidectomy should be considered.

Antisynthetase Syndrome: The Classical Phenotype With a Twist.

Antisynthetase syndrome is a systemic autoimmune rheumatic disease characterized by multiple organ involvement, including interstitial lung disease, myositis, non-erosive arthritis, fever, Raynaud's phenomenon, "mechanic's hands," and the presence of autoantibodies against aminoacyl-tRNA synthetases, mainly anti-Jo1 (histidyl) antibodies. Patients with antisynthetase syndrome and active muscle inflammation are usually presented with elevated creatine phosphokinase levels, even in the range of acute rhabdomyolysis. Despite that, the presence of myoglobinuric acute kidney injury is rarely seen in patients with myositis-associated rhabdomyolysis. Herein, we report the case of a 64-year-old man who presented with acute kidney injury due to severe rhabdomyolysis in the setting of antisynthetase syndrome diagnosed by the classical clinical triad of (1) interstitial lung disease, (2) non-erosive arthritis, and (3) active myositis and the presence of anti-Jo1 antibodies. The diagnosis was confirmed by muscle biopsy histological findings as well as electromyography. In this case report, we also discuss the classical clinical manifestations of antisynthetase syndrome and a twist toward this unusual complication associated with active muscle inflammation.

Dermatoscopy of melanoma according to type, anatomic site and stage.

The indisputable contribution of dermatoscopy in early diagnosis of melanoma is widely recognized. In the last quinquennium, new data concerning specific melanoma subtypes have come to light. The dermatoscopic morphology of superficial spreading melanoma (SSM) has been extensively investigated in the literature. Atypical network, irregular dots, irregular globules, irregular streaks and irregular blotch correspond to histopathologic alterations at the level of the junction, blue-white veil and atypical vessels suggest intradermal growth, whereas regression structures, negative network and white shiny streaks might reflect junctional or dermal alterations. The list of melanoma specific criteria has been recently updated to include features that typify early melanoma, such as irregular hyperpigmented areas and prominent skin markings and features seen in melanoma on sun damaged skin such as angulated lines. Nodular melanoma lacks most of the aforementioned criteria and is typified by the coexistence of blue and black color, atypical vessels and pink color. Lentigo maligna dermatoscopic criteria mainly develop at the outline of the follicular openings. However, at an early stage these features might be very subtle and the diagnosis should be based on the exclusion of benign tumors (inverse approach). Acral lentiginous melanoma is typified by a parallel ridge pattern, but also SSM criteria should be taken into consideration. The diagnosis of subungual melanoma is based on the assessment of the color and characteristics of the pigmented nail band. For the diagnosis of mucosal melanoma, the assessment of colors is more informative than the assessment of structures and the detection of blue, white or gray should raise the suspicion of melanoma. White shiny streaks and regression structures are the most common features of desmoplastic melanoma. The diagnosis of nevoid melanoma might be highly challenging and require information on the lesion's history. Melanoma on small- and medium-sized congenital nevi is typified by an eccentric location of the suspicious area, negative network and gray angulated lines. Recent advances in knowledge on the dermatoscopic characteristics of peculiar subtypes of the tumor significantly enrich the diagnostic armamentarium of clinicians. The challenge of the forthcoming years is to better characterize biologically aggressive melanomas and to optimize the screening strategies so as to identify them.

Real-life data on basal cell carcinoma treatment: Insights on clinicians' therapeutic choices from an institutional hospital registry.

Basal cell carcinoma (BCC) is the most common skin cancer in white skin individuals. The treatment of choice is surgical excision, but several other therapeutic choices are available and might also be efficient and cost-effective in selected cases of low-risk BCC or when surgery is complicate or contraindicated. The aim of the current study was to analyze the applied treatments for BCC in the real-life practice of a tertiary hospital, and investigate factors associated to the tumor and the patients that might influence the treatment selection of clinicians. Data on all BCCs treated from 1st January 2018 to 31st December 2019 were extracted. A total of 751 BCCs from 585 patients were included. The baseline characteristics of patients and tumors, the type of applied treatment and the histopathologic report when available were analyzed. Most tumors were located on the head/neck (64.2%). The most frequently applied treatment was surgical excision (580/751, 77.2%). In 22.8% of tumors a nonsurgical treatment was selected. The most frequently selected alternative treatments were, imiquimod, cryosurgery, their combination (immunocryosurgery), and vismodegib. A pretreatment diagnosis of superficial BCC was associated with a 12-fold increased probability of selecting a nonsurgical treatment except of vismodegib. Every added year of age increased the probability of selecting a nonsurgical treatment by 3-fold. Every added mm of diameter increased the possibility of vismodegib use by 4%. Surgery is the most frequently applied BCC treatment, but nonsurgical modalities do also have an essential role in real settings.

Flaws in Anticoagulation Strategies in Patients With Atrial Fibrillation at Hospital Discharge.

BACKGROUND: Proper anticoagulation is a crucial therapeutic regimen in atrial fibrillation (AF). OBJECTIVES: To evaluate the real-life anticoagulation prescriptions of AF patients upon hospital discharge. METHODS: We studied 768 patients with comorbid AF who were discharged from the cardiology ward of a tertiary hospital. We assessed the appropriateness of oral anticoagulation (OAC) regimens at discharge based on stroke risk (CHA2DS2-Vasc score), SAMe-TT2R2 (sex, age, medical history, treatment, tobacco, race) score for vitamin K antagonists (VKA), and European labeling for nonvitamin K oral anticoagulant (NOAC) dosing. Logistic regression identified factors associated with suboptimal OAC use. RESULTS: Of 734 patients at significant (moderate or high) stroke risk, 107 (14.6%) were not prescribed OAC, which was administered to 23 (67.6%) of 34 patients at low risk. Nonprescribing of OAC to high-risk patients was associated with paroxysmal AF (adjusted odds ratio [OR]: 2.42, 95% confidence interval [CI]: 1.47-3.99, P < .001), history of major bleeding (adjusted OR: 1.89, 95% CI: 1.03-3.47, P = .039), and concomitant antiplatelet use (adjusted OR: 5.78, 95% CI: 3.51-9.51, P < .001). Anticoagulation control was inadequate (SAMe-TT2R2 score > 2) in 102 (50.2%) VKA-treated patients. Off-label dosing was evident in 118 (28.9%) NOAC-treated patients and was associated with a prior stroke/transient ischemic attack (adjusted OR: 2.06, 95% CI: 1.10-3.85, P = .023). Both outcomes were independently associated with low creatinine clearance. CONCLUSIONS: One of 6 patients with AF newly discharged from the hospital was treated discordantly for the corresponding risk of stroke. Suboptimal OAC use was evident in half of VKA regimens, twice as common compared to NOACs, and could be predicted by several clinical parameters.

Ossification of the cervical ligamentum flavum and osseous brown tumor: late manifestations of primary hyperparathyroidism misdiagnosed in a case of parathyroid carcinoma.

Parathyroid carcinoma represents an extremely rare neoplasm with diverse clinical manifestations. Herein we aimed at presenting an unique case of a young patient with late manifestations of parathyroid cancer and reviewing the relevant literature. A 45-year-old male patient presented in the Outpatient Clinic with an episode of nephrolithiasis. His personal medical history includes: recurrent episodes of nephrolithiasis, laminectomy in the cervical spine due to ossification of the cervical ligamentum flavum and surgical resection of a giant cell tumor of the brain. Laboratory testing revealed findings of primary hyperparathyroidism (serum calcium 16,0 mmol/l phosphorus 1,46 mg/dl and parathyroid hormone/PTH 8560 pg/ml). Neck ultrasound and technetium-99 m sestamibi scan were performed showing a parathyroid tumor. Due to the persistently high serum calcium and PTH levels, the high alkaline phosphatase levels (440 IU/L) and the late manifestations of HPT, surgical excision of the tumor was performed. The tumor was identified as parathyroid carcinoma. Immediately after surgery serum calcium and phosphorus levels were normalized. The patient is on a regular follow-up program with no signs of recurrence or metastasis one year after the excision. We describe the coexistence of rare late manifestations of HPT, which had not been adequately investigated at their onset in this young patient. Therefore, increased awareness is needed in order to recognize and further investigate signs or symptoms of HPT.

Renal manifestations of human brucellosis: First report of minimal change disease.

Human brucellosis is considered a great example of the complexity of clinical manifestations possibly affecting multiple organs or systems. Renal manifestations of human brucellosis have been documented in few case reports and one case series. Herein, we present a case of Nephrotic syndrome (NS) due to minimal change disease in the course of acute brucellosis. A 53-year-old male farmer was admitted to our department with acute brucellosis and NS. Renal biopsy revealed minimal change disease. Combined treatment with prednisone (1 mg/kg), rifampicin (600 mg/day), and doxycycline (200 mg/day) was initiated. Complete remission of NS was achieved at the end of the fourth week. One year later, the patient remained in complete remission of NS without any sign of relapse of brucellosis.

Rare Skeletal Complications in the Setting of Primary Hyperparathyroidism.

Parathyroid carcinoma represents an extremely rare neoplasm with diverse clinical manifestations which vary from asymptomatic patients to severe complications of hypercalcemia or parathyrotoxicosis while skeletal involvement is rather common. Herein we aimed at presenting a unique case of a young patient with rare aggressive skeletal complications of parathyroid cancer that initially were misdiagnosed. Ossification of the cervical ligamentum flavum and skull tumor illustrates erosive bonny lesions of hyperparathyroidism that in association with previous medical history of recurrent nephrolithiasis and biochemical findings guide the diagnosis. We suggest that increased awareness and holistic approach are needed in order to recognize and further investigate signs and symptoms of hyperparathyroidism.

Unexpected Abscess Localization of the Anterior Abdominal Wall in an ADPKD Patient Undergoing Hemodialysis.

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is one of the most common monogenic disorders and the leading inheritable cause of end-stage renal disease worldwide. Cystic and noncystic extrarenal manifestations are correlated with variable clinical presentations so that an inherited disorder is now considered a systemic disease. Kidney and liver cystic infections are the most common infectious complications in ADPKD patients. Furthermore, it is well known that ADPKD is commonly associated with colonic diverticular disease which recently has been reported to be linked to increased risk of infection on hemodialysis patients. Herein, we present a case of anterior abdominal wall abscess caused by Enterococcus faecalis in a patient with ADPKD undergoing hemodialysis. Although the precise pathway of infection remains uncertain, the previous medical history as well as the clinical course of our patient led us to hypothesize an alternative route of infection from the gastrointestinal tract through an aberrant intestinal barrier into the bloodstream and eventually to an atypical location.

Hypofibrinogenemia induced by tigecycline: a potentially life-threatening coagulation disorder.

A 74-year-old female patient with end-stage renal disease, undergoing periodic hemodialysis, was hospitalized due to infection by multidrug-resistant Acinetobacter baumannii after hip replacement surgery. She was treated with tigecycline, a glycylcycline agent. Subsequently she developed coagulation disorders as substantiated by increased international normalized ratio (INR), prolonged partial thromboplastin time (aPTT), and severe hypofibrinogenemia, followed by transaminasemia, cholestasis, and anemia. Ultrasonography and computed tomography revealed no underlying pathological entities. Tigecycline was discontinued and the patient underwent daily hemodialysis and received multiple fresh frozen plasma transfusions. Additionally, she was treated with colistin. Her clinical and laboratory status improved. We suggest that patients treated with tigecycline should be monitored for changes in INR, aPTT, and fibrinogen levels to avoid severe, life-threatening coagulation disturbances.

Splenic infarction as a rare complication of infectious mononucleosis due to Epstein-Barr virus infection in a patient with no significant comorbidity: case report and review of the literature.

We report the case of a 17-y-old boy diagnosed with infectious mononucleosis due to Epstein-Barr virus infection who complained of left upper quadrant pain. A magnetic resonance imaging scan showed a splenic infarct in the enlarged spleen. Other causes of splenic infarction were excluded. Thus, infectious mononucleosis may cause splenic infarction in patients without other comorbidities.