Rhabdomyolysis-induced acute kidney injury in a cancer patient exposed to denosumab and abiraterone: a case report.

BACKGROUND: Denosumab and abiraterone were approved by the United States Food and Drug Administration in 2011 for the treatment of metastatic castration-resistant prostate cancer. Neither denosumab nor abiraterone is known to cause rhabdomyolysis. CASE PRESENTATION: A 76-year-old Caucasian man with metastatic prostate cancer presented with non-oliguric severe acute kidney injury (AKI) 3 weeks after receiving simultaneous therapy with denosumab and abiraterone. The patient had been on statin therapy for more than 1 year with no recent dose adjustments. His physical exam was unremarkable. Blood work on admission revealed hyperkalemia, mild metabolic acidosis, hypocalcemia, and elevated creatine kinase (CK) at 44,476 IU/L. Kidney biopsy confirmed the diagnosis of rhabdomyolysis-induced AKI. The patient responded well to intravenous isotonic fluids and discontinuation of denosumab, abiraterone, and rosuvastatin, with normalization of CK and recovery of kidney function. CONCLUSION: We report the first case of biopsy-proven rhabdomyolysis-induced AKI in a cancer patient acutely exposed to denosumab and abiraterone. Whether one of these drugs individually, or the combination, was the bona fide culprit of muscle breakdown is unknown. Nonetheless, our report is hypothesis-generating for further investigations on the effect of these drugs on muscle cells.

Cocaine induced pleural and pericardial effusion syndrome.

A 42-year-old African American female with chronic cocaine use for 20 years, presented with two-day history of exertional shortness of breath and pleuritic chest pain. She was admitted three years back with acute kidney injury and skin rashes. At that time, skin biopsy was consistent with leukocytoclastic vasculitis and renal biopsy revealed proliferative glomerulonephritis. She responded to oral prednisone and mycophenolate with complete recovery of her kidney functions. Skin rash was waxing and waning over the last two years. On the second admission, patient was found to have large pleural effusion on computerized tomography scan and pericardial effusion on echocardiogram as shown in the figures. Pleural fluid analysis was exudative. Her serology was negative for ANA (antineutrophilic antibody) and anti-dsDNA (double stranded DNA). Complements levels were normal. She had positive low titers of ANCA levels. The patient was started on a course of prednisone for 6 months. Her pleural and pericardial effusion resolved completely on follow-up imaging with computerized tomography scan and echocardiogram. This case is unique since the pericardial and pleural effusions developed without any other etiology in the setting of cocaine; hence, we describe this clinical syndrome as cocaine induced pleural and pericardial effusions syndrome (CIPP).

Collapsing focal segmental glomerulosclerosis resulting from a single dose of zoledronate.

Bisphosphonates are commonly used for the treatment of osteoporosis, Paget's disease, multiple myeloma and hypercalcemia. Collapsing focal segmental glomerulosclerosis (FSGS) is known to occur uncommonly with exposure to bisphosphonates, specifically pamidronate and alendronate; it has rarely and equivocally been reported with zoledronate therapy. We describe the case of a 36-year-old African American female with metastatic breast cancer who presented with nephrotic-range proteinuria and acute kidney injury within 2 weeks of exposure to a single dose of zoledronate. The patient had a partial recovery of her renal function and showed improved proteinuria to a subnephrotic level after discontinuing zoledronate. In contrast to 2 prior reports of zoledronate-induced collapsing FSGS, the causative role of the exposure described here is certain. Our case necessitates the addition of zoledronate to the list of known causes of collapsing FSGS. Furthermore, it highlights the importance of periodically monitoring renal function and urine protein excretion with the use of zoledronate, which allows prompt diagnosis and withdrawal of the drug to increase the probability of renal recovery.

Role of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in isolated pancreatic metastasis from lung cancer.

A case is reported of a 50-year-old woman with a history of small-cell lung cancer admitted with pancreatic head lesions, discovered during investigation for obstructive jaundice. Endoscopic ultrasound assisted fine needle aspiration of the pancreatic mass was consistent with small cell carcinoma, presenting as an isolated metastasis from the previously diagnosed lung cancer. Endoscopic retrograde cholangiopancreatography (ERCP) showed extrinsic compression and a bile duct stricture, requiring sphincterotomy and stent insertion. This case highlights that acute pancreatitis and biliary obstruction can occur as a manifestation of small cell lung cancer metastasizing to the pancreas. EUS is a safe, low risk and rapid diagnostic tool in such cases, and ERCP with stenting offers a safe and effective treatment option.

Risk of bleeding after percutaneous endoscopic gastrostomy (PEG).

BACKGROUND: Patients who undergo percutaneous endoscopic gastrostomy (PEG) placement are often on anticoagulation and/or antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. Data on the safety of peri-procedural use of these drugs is limited. AIMS: To assess the risk and to identify any predictive factors for post-PEG bleeding, and to determine if clopidogrel increases the risk of bleeding following PEG. METHODS: A retrospective chart audit was conducted from January 1, 2002 to June 30, 2011. RESULTS: A total of 1,541 patients underwent PEG placement during this period. Gastrointestinal bleeding after PEG placement occurred in 51 cases (3.3%) and bleeding directly attributed to PEG was noted in six patients (0.4%). Multivariate logistic regression analysis of variables (age, gender, length of hospitalization, indication for PEG, antiplatelet or anticoagulant medications) showed that heparin infusion (P = 0.018) and length of hospitalization (P = 0.029) were statistically significant predictors of bleeding. The mean period for cessation and resumption of clopidogrel with PEG placement were 2.2 and 1.3 days, respectively. CONCLUSION: Although PEG is classified as a high-risk endoscopic procedure, bleeding with PEG placement was rare, even with use of anticoagulation and antiplatelet medications. In selected patients on heparin infusion undergoing PEG, delaying the procedure, alternative use of low-molecular-weight heparin or close monitoring and frequent assessments should be considered. Clopidogrel did not contribute to an increase in bleeding risk, despite being held for a much shorter peri-procedural period as recommended by expert consensus.

Usefulness of multimodality cardiac imaging in the diagnosis of a right atrial angiosarcoma.

A 78-year-old woman presented with progressive dyspnea and atrial flutter and was found to have a right atrial mass. Multimodality cardiac imaging was useful in further characterizing this mass, which was ultimately diagnosed after biopsy as a low-grade angiosarcoma.