Amiodarone-Induced Immune Thrombocytopenia: A Rare Hematologic Side Effect of a Common Cardiac Drug.

Thrombocytopenia is a rare immune-mediated hematologic complication of amiodarone. We describe a case of delayed-onset amiodarone-induced thrombocytopenia in a 72-year-old male and highlight the process of working it up. A timely diagnosis of drug-induced immune thrombocytopenia is crucial in order to minimize unnecessary testing, avoid treatments with potential harm, and prevent life-threatening hemorrhagic complications.

Triple-Negative Lobular Breast Cancer Causing Hydronephrosis.

Breast cancer is the leading malignancy and the second most common cause of mortality in women. Although there have been advances in identifying biomarkers as potential targets for therapy, triple-negative breast cancer (TNBC) continues to have a poorer prognosis than the other receptor subtypes. The most common sites of metastasis are bone, liver, lung, and brain. We present a patient with known TNBC presenting with nausea and vomiting in whom computed tomography revealed a right-side pelvic mass causing hydronephrosis. Biopsy was consistent with TNBC of the ureter, an unusual site for breast cancer involvement. She required ureteral stent placement to relieve obstruction and has had good response to paclitaxel. Hydronephrosis due to malignancy presents significant risk of morbidity and mortality due to compromised renal function and must be resolved promptly to avoid compromise of renal function.

Effect of blood group on idiopathic thrombotic thrombocytopenic purpura.

Thrombotic thrombocytopenic purpura (TTP) is a condition caused by deficiency of ADAMTS13 resulting in accumulation of ultra large Von Willebrand factor multimers (ULVWF), leading to micro thrombi in multiple organs. The varying susceptibilities of blood group antigens to ADAMTS13 have been demonstrated. A and B antigens are protective of VWF; and VWF purified from blood group O individuals has been shown to be cleaved faster by ADAMTS13 compared to VWF from blood group AB individuals. We proposed that there may be a difference in the incidence of blood groups in TTP patients compared with the general population. We felt this to be important for a life-threatening disease with poorly understood epidemiology. We report a retrospective analysis of 74 patients presenting from 1993 to 2008 with idiopathic TTP. We studied the incidence across various blood groups and also estimated the recurrence and mortality in each group. The incidence of various blood groups were as follows: O 36%, A 36%, B 25%, and AB 2%, compared with expected frequencies in the Detroit area: O 44%, A 33% B 20%, and AB 3%. There was a trend of lower than expected frequency of blood group O. There were 24 recurrences and 14 deaths, uniform across blood groups. We hypothesized that there may be an association between blood groups and the risk of TTP; however the differences in our study were not statistically significant. Recurrence and disease specific mortality did not appear to be impacted by blood group.

PARP Inhibitor Olaparib Use in a BRCA1-Positive Patient With Metastatic Triple-Negative Breast Cancer, Without the Initial Use of Platinum-Based Chemotherapy, Showing Significant Rapid Near Resolution of Large Liver Metastasis While Patient Experienced Gout-Like Symptoms.

Triple-negative breast cancer (TNBC) accounts for 20% of breast cancers diagnosed worldwide. This subtype of breast cancer tends to behave more aggressively, and unlike other breast cancer subtypes, there are no standard targeted treatments for most patients. However, up to 20% of patients with TNBC harbor a breast cancer gene (BRCA) mutation, particularly in BRCA1. For patients who carry this gene mutation, this opens the door for new management options by the use of newer agents such as polyadenosine diphosphate-ribose polymerase (PARP) inhibitors in the metastatic setting. Given that this is uncommon and that PARP inhibitors have only recently received Federal Drug Administration approval, the experience with these drugs is relatively new. In this article, we present a case of a patient treated in this setting with olaparib who developed an unanticipated side effect as a result of the high efficacy of the drug.

A Rare Case of Triple Positive Metachronous Breast Cancer.

Metachronous contralateral breast cancer (MCBC) is defined as contralateral breast cancer (BC) diagnosed more than 1 year after previous BC diagnosis. More BC survivors are at risk of MCBC given improved life expectancy with the availability of advanced cancer care. Estrogen receptor/progesterone receptor negative and HER-2-positive status of first BC are independent risk factors for the development of MCBC. We present a rare case of triple positive (estrogen receptor, progesterone receptor, HER-2 positive) MCBC patient who eventually developed brain metastasis within 15 months despite a near complete pathologic response of primary tumor. This case highlights that even in this era of antiestrogen and anti-HER-2 therapies, triple positive MCBC can have an aggressive clinical course, especially with brain metastasis as the first sign of metastasis.

Concurrent Squamous Cell Carcinoma and Chronic Lymphocytic Leukemia Presenting as an Enlarging Neck Mass.

Chronic lymphocytic leukemia (CLL) patients are at an increased risk for developing more aggressive lymphomas via Richter's transformation and of developing secondary malignancies. Despite the known association for secondary cancers, oropharyngeal cancers occur rarely. We present a case of a woman with a history of CLL who presented to our facility via transfer for impending airway compromise. Her initial workup was consistent with CLL; however, biopsies were taken of the neck mass because of its aggressive nature. She was treated with rituximab with good response. Final pathology showed evidence of CLL and tonsillar squamous cell carcinoma (SCC). Direct laryngoscopy and further biopsies yielded a diagnosis of unresectable oropharyngeal SCC. She was to be treated with chemotherapy and radiation for her SCC while holding treatment for CLL. This case demonstrates a rare and unexpected concurrent diagnosis.

Langerhans Cell Histiocytosis Presenting as Progressively Worsening Neck Pain: A Case Report With a Review of Literature.

A 29-year-old female with past medical history of chronic serous otitis media presented with worsening neck stiffness and pain over a period of 2 weeks. The patient described non-specific symptoms that were localized to the right side of her neck. She presented to the hospital only when the pain was so extreme that it limited her range of motion. The differential for acute neck pain without fever, chills or any inciting trauma is vast. They include medical emergencies such as meningitis, acute coronary syndromes and extend to rheumatologic diseases or simply musculoskeletal strain. On review of systems, she denied dizziness, headache, vision changes, dysphagia, or other facial pain. Based on the severity of her pain, she underwent a Computed Tomography scan of the neck, which was concerning for erosive calavarial lesions. Further imaging revealed multiple lytic foci and erosions from the right maxillary sinus to the right mandible to the C1 vertebra. Following requisite surgical intervention, she was found to have Langerhans cell histiocytosis, a rare disease of myeloid cells, usually affecting pediatric populations. Little is known about the adult manifestations of Langerhans Cell Histiocytosis. This review contributes to broadening the literature on this topic which can present with complaints as typical as neck pain.

Coexistent Breast Cancer and Essential Thrombocythemia: How We Addressed the Therapeutic Challenges.

Essential thrombocythemia (ET) occurring with breast cancer is uncommon; the therapeutic approach varies and poses a challenge. A 65-year-old female presented to us after being diagnosed with hormone positive, HER2-negative infiltrating ductal carcinoma. She had a platelet count of 600 thou/cu mm. Her JAK2 mutation was positive. Bone marrow biopsy showed increased megakaryocytes. She was diagnosed with ET in the setting of breast cancer. She underwent breast conservation surgery after which aspirin was resumed. Anticipating thrombocytopenia during chemotherapy and given the absence of data combining hydroxyurea with standard chemotherapy used for breast cancer, we felt it prudent to delay cytoreductive therapy for her ET until after completion of breast cancer treatment. Her average platelet count during chemotherapy was 480 thou/cu mm with the lowest being 377 thou/cu mm. Her platelet count remained at goal between 300 and 350 thou/cu mm after four months of hydroxyurea.

Immune Thrombocytopenia as a Consequence of Rocky Mountain Spotted Fever.

Primary immune thrombocytopenia (ITP) - also called idiopathic thrombocytopenic purpura or immune thrombocytopenic purpura - is an acquired thrombocytopenia caused by autoantibodies against platelet antigens. It is one of the more common causes of thrombocytopenia in otherwise asymptomatic adults. Rocky Mountain spotted fever (RMSF) is a potentially lethal, but curable, tick-borne disease. We present a case of ITP that was triggered by RMSF.

Increased risk of arterial thromboembolic events with combination lenalidomide/dexamethasone therapy for multiple myeloma.

INTRODUCTION: Cancer associated thrombosis is a leading cause of morbidity and mortality. Research and guidelines have focused on venous thromboembolic events (VTE). Within the past decade, combination lenalidomide and dexamethasone has become a standard of therapy for multiple myeloma and is now widely used. In these patients, the risk of arterial thromboembolic events (ATE) has not been addressed to the same extent as VTE. Areas discussed: Presented is a targeted review of published data on ATE in MM patients on combination lenalidomide/dexamethasone therapy. Incidence, clinical presentations, prognosis, mechanisms and thromboprophylaxis are discussed. A framework for approaching ATE/VTE in these patients is suggested. Expert commentary: There is an increased incidence of ATE in this population, primarily cerebrovascular and cardiovascular events. ATE is associated with poorer prognosis and its prevention must be an important goal of management. It is suggested that on initiating treatment, a combined VTE/ATE risk assessment should be performed and thromboprophylaxis initiated for a minimum of 6 months. As newer immunomodulatory therapies are developed, thromboembolic risk must be assessed early on. Further studies are needed to determine the optimal strategy to reducing both VTE and ATE in this population.

Letrozole-induced hepatitis with autoimmune features: a rare adverse drug reaction with review of the relevant literature.

While aromatase inhibitors (AIs) have been known to cause minor elevations in liver enzymes, severe hepatotoxicity is rare. To the best of our knowledge, this is the first reported case of Letrozole-induced hepatitis with autoimmune features. A 70-year-old female with estrogen positive, invasive ductal carcinoma of the breast, presented with jaundice 3 months after starting letrozole. Hepatic transaminases were markedly elevated and her ANA and anti-smooth muscle antibody was positive. Liver biopsy featured drug-induced hepatitis. After stopping letrozole, liver tests trended back to normal within 3 weeks. She scored 9 for Roussel-Uclaf Causality Assessment Method (RUCAM). Over the last 10 years, there have been reported cases of drug-induced hepatitis secondary to AIs. We anticipate that there will be more widespread use of AIs based on recommendations from the TEXT, SOFT and extended AI trials. Therefore, physicians must be aware of this rare but life-threatening complication.

Mycobacteria Bovis osteomyelitis following intravesical BCG for bladder cancer.

Mycobacteria Bovis osteomyelitis is a rare adverse effect after Bacillus Calmette-Guerin (BCG) intravesical therapy. A 62-year-old male presented with acute spinal cord compression three months after completing his second course of therapy for bladder cancer. The first course with intravesical BCG was complicated with an episode of hematuria. He reported intermittent subjective fever for 3 weeks thereafter which resolved with Tylenol. Interferon-α2 B was added to the second cycle of intravesical BCG with the indication here being residual tumor, and was tolerated well. His complete blood count and liver function tests were unremarkable on admission. MRI showed features of osteomyelitis with cord compression at T4/T5. Biopsy of the affected bone showed caseating granuloma which was positive for acid fact bacilli, later confirmed to be Mycobacterium Bovis by PCR and pyrazinamide resistance. He was started on intravenous steroids and underwent spinal cord decompression. Rifampin, Isoniazid, and Ethambutol were then commenced. His weakness improved and after two months of therapy he was asymptomatic and back to his baseline function. Osteomyelitis is a rare but serious complication. Early diagnosis and treatment is important as the outcomes are good.

Relationship of Gender and Smoking History in the Development of Hypothyroidism From Exposure to External Beam Radiation for Head and Neck Cancers.

BACKGROUND: Patients with head and neck cancers (HNCs) are often treated with external beam radiation therapy (XRT). Unfortunately this therapy is not without its unintended consequences. One of these side effects includes the development of radiation-induced hypothyroidism. Our study is designed to pay special attention to variables like gender and smoking history and analyze their relationship with the development of hypothyroidism. METHODS: Patients' charts were reviewed over a period of 13 years from January 1, 2000 to November 30, 2013 to gather information on patients who had previously received XRTs for HNCs. We used the Tumor Registry Database at the University of Florida, College of Medicine in Jacksonville for this retrospective review. Patient characteristics were examined including age, gender, race/ethnicity and smoking history. Special attention was paid to the development of hypothyroidism (thyroid stimulating hormones > 5.0 with appropriate decrease in free serum T4) levels after exposure to XRT for HNCs. Results were then analyzed using the univariate statistical analysis which was done using the SAS software using a 0.05 alpha level of significance expressed in terms of odds ratio (OR) with 95% confidence intervals (CIs). RESULTS: We found a total of 1,116 patients in our database who have received XRTs for HNCs. Out of these 72 (6.45%) patients developed hypothyroidism. Out of 263 African American patients 20 (7.6%) had hypothyroidism, whereas 49 (6%) out of 819 white people had this outcome. As for gender 32 out of 341 females (9.4%) and 40 out of 775 males had hypothyroidism. Thirty-five out of 544 (6.4%) with no family history and 19 (2.4%) out of 205 (9.3%) with positive family history for cancer had the outcome too. Finally 43 (6.5%) out of 664 smokers and 17 (8.3%) out of 206 non-smokers were found to develop hypothyroid as well. Both groups were found to have homogenous average age at diagnosis. When the univariate analysis was conducted, the strongest predicting variable was gender as hypothyroid patients were 1.90 (95% CI 1.17 - 3.09) times more likely to be females, and these results were statistically significant with P value of 0.008. More patients tended to be African Americans with OR 1.21 (CI 0.822 - 1.78), had positive family history of cancer (negative family history had OR 0.67 (CI 0.38 - 1.21), and less likely to be smokers (OR 0.77 (0.43 - 1.38). However, race, family history of cancer and smoking history did not achieve any statistical significance as evident by the P values. CONCLUSION: In our patient population, females were more likely to develop radiation-induced hypothyroidism.

A rare case of cardiac paraganglioma presenting as anginal pain: a case report.

INTRODUCTION: Primary cardiac paraganglioma is a very rare tumor with less than sixty reported cases in the literature. The clinical presentation is variable, but is most commonly manifested by hypertension and symptoms related to the catecholamine excess. CASE REPORT: We report a case of a 35 year old man who presented with anginal pain and hypertension. He was found to have a cardiac mass on the computed tomographic scan and echocardiogram. He underwent surgical exploration of the mass which on biopsy was found to be a 'Cardiac Paraganglioma'. Surgical resection of the tumor was successfully done and the patient is doing well five years after the surgery without any evidence of recurrence. His blood pressure, however, failed to normalize and needed single agent antihypertensive therapy. CONCLUSION: Cardiac paragangliomas have a relatively favorable outcome if diagnosed and resected in time. We briefly review the literature regarding the diagnosis, treatment and prognosis of this rare tumor.