Warfarin induced leukocytoclastic vasculitis: an extraordinary side effect.

Warfarin is one of the most commonly used anticoagulants in the management of thromboembolic events. Herein we report a rare case of warfarin induced leukocytoclastic vasculitis in a patient with history of rheumatic heart disease and a mechanical mitral valve prosthesis who presented with heart failure and palpable purpura. Upon clinical suspicion of cutaneous small vessel vasculitis, a comprehensive laboratory panel was performed. Warfarin induced vasculitis was suspected when withdrawal of warfarin, due to rising INR, led to improvement of the skin lesions. The diagnosis was finally confirmed when re-instatement of warfarin reproduced the skin lesions and a skin biopsy showed evidence for leukocytoclastic vasculitis with eosinophilic infiltration. A third of cases of leukocytoclastic vasculitis are due to drug hypersensitivity which being a diagnosis of exclusion with varying manifestations, requires a high index of clinical suspicion. Since drug induced leukocytoclastic vasculitis may affect multiple organ systems and even cause mortality, clinicians must be aware of this rare adverse event, promptly discontinue the drug, and commence anti-inflammatory or immunosuppressive treatment when necessary.

Enoxaparin induced eruptive angiokeratoma, an extremely rare side effect.

Enoxaparin is one of the most commonly used anticoagulants in the management of thromboembolic events. Herein we report a unique case of enoxaparin induced eruptive angiokeratomas in a patient with a history of ischemic cardiomyopathy who presented with acute decompensated heart failure and a new-onset generalized skin rash that bleeds on trauma, suggestive of angiokeratomas. Dermoscopic examination, as well as skin biopsy, were done upon clinical suspicion of eruptive angiokeratomas, to confirm the diagnosis. Dermoscopy showed dark lacunae surrounded by erythema, while skin biopsy revealed dilated congested capillaries lined by flat endothelial cells in the papillary dermis, both confirming the diagnosis of angiokeratoma. Enoxaparin induced eruptive angiokeratomas was suspected when the skin eruption showed spontaneous dramatic resolution upon withdrawal of enoxaparin followed by its substitution with warfarin, during the course of the patient's treatment. Enoxaparin induced eruptive angiokeratoma is an extremely rare side effect. Physicians should have a high index of clinical suspicion, and promptly discontinue the drug, as this is the only proven treatment for this condition.

CD19-targeted chimeric antigen receptor T-cell therapy in patients with concurrent B-cell Non-Hodgkin lymphoma and rheumatic autoimmune diseases: a propensity score matching study.

Rheumatic autoimmune diseases not only involve the production of autoantibodies but also demonstrate T-cell dysfunction. In patients with concurrent B-cell non-Hodgkin lymphoma (NHL) and rheumatic autoimmune diseases, the safety and efficacy of CD19-targeted chimeric antigen receptor (CAR) T-cell therapy are unknown. Using an aggregated electronic health record database, patients with rheumatic autoimmune diseases (auto group) were compared to propensity score-matched patients without rheumatic autoimmune diseases (non-auto group). From 1/2019 to 1/2023, 58 (4.3%) of 1,363 patients who received CD19-targeted CAR T-cell therapy had concurrent rheumatic autoimmune diseases. Both groups had similar incidence, severity, and management of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Moreover, the two groups had similar time-to-next treatment or death (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.60 to 1.59, log-rank p = 0.91) and overall survival (HR 0.90, 95%CI 0.46 to 1.78, p = 0.76). Following CAR T-cell infusion, patients with rheumatic autoimmune diseases achieved decreased inflammatory markers, seronegative conversion of autoantibodies, as well as reduced use of steroids and disease-modifying anti-rheumatic drugs. In conclusion, the safety and efficacy of CAR T-cell therapy were not affected in patients with rheumatic autoimmune diseases. Moreover, they achieved better biochemical control of underlying rheumatic diseases.

Humoral hypercalcaemia of malignancy associated with a gigantic cutaneous squamous cell carcinoma.

Humoral hypercalcaemia of malignancy is rarely associated with cutaneous squamous cell carcinoma (SCC), and only a few cases have been reported in the medical literature. We present an interesting case of a gigantic cutaneous SCC associated with severe hypercalcaemia.A man in his mid 80s presented with a rapidly enlarging fungating mass of his scalp for 5 months. Laboratory studies logged severe hypercalcaemia, low intact parathyroid hormone, elevated parathyroid hormone related-peptide and normal 1,25 dihydroxy vitamin D. Skin biopsy revealed moderately differentiated invasive SCC. Further workup was negative for distant skeletal metastases. Severe hypercalcaemia was managed by intravenous fluids, bisphosphonates and calcitonin. A multidisciplinary approach was then made; the patient received radiotherapy and then underwent a successful surgical resection. By presenting this case, we aim to raise physicians' awareness of the association between cutaneous SCC and hypercalcaemia. Severe hypercalcaemia should be detected early and promptly managed as it could be fatal.

Grade III solitary fibrous tumor/hemangiopericytoma: An enthralling intracranial tumor-A case report and literature review.

Hemangiopericytomas account for less than 1% of all intracranial tumors. In 2016, World Health Organization (WHO) unified the two terms into a single medical condition known as solitary fibrous tumor/hemangiopericytoma (SFT/HPC). Our patient is an 80-year-old woman with a past medical history of sick sinus syndrome status post pacemaker placement. She presented to the emergency department with progressive headaches for one month duration. Her headaches worsened at night, waking her up from sleep. They also increased in intensity by bending forward. Review of systems was significant for bilateral lower extremity weakness accompanied by difficulty walking. The motor exam was remarkable for right upper and right lower extremity 3/5 weakness. The gait was ataxic. A Computed tomography scan of the head without contrast revealed a large dural-based right parietal hyperdense mass with surrounding edema, mass effect, and compression of the right lateral ventricle atrium. A right-to-left midline shift was also noted. Given the fact that our patient had a pacemaker, she was not a candidate for a brain MRI. Neurosurgery successfully resected the mass. Histopathological studies confirmed WHO grade III anaplastic solitary fibrous tumor/hemangiopericytoma. The patient was discharged on adjuvant radiation with imaging surveillance given the grade and the extent of resection. This case highlights a rare type of intracranial mass that resembles meningioma on imaging studies. It also illustrates that solitary fibrous tumor/hemangiopericytoma should be kept as a differential diagnosis for brain masses, given its aggressive nature, and its potential of metastasis and recurrence.

Expression of retinoid receptors in hand eczema.

BACKGROUND: Hand eczema is the most common occupational skin disease. The etiology is multifactorial. Systemic alitretinoin, a pan-retinoic receptor agonist, has proven efficacy in the treatment of recalcitrant chronic hand eczema; however, its precise mechanism of action in hand eczema is not fully understood. AIMS: Assessment of the level of expression of retinoid receptors (RAR and RXR) in the skin of patients with hand eczema in an attempt to explain their possible role in the pathogenesis of the disease. METHODS: Thirty patients with hand eczema and 30 age- and sex-matched healthy controls were included. Full clinical examination was done, and tissue levels of retinoic acid receptor (RAR) and retinoid x receptor (RXR) were measured by quantitative real-time PCR (qRT-PCR). RESULTS: The levels of RAR and RXR expression were significantly downregulated in the patient group compared to the control group; (P < 0.001) for both. In addition, there was a statistically significant negative correlation between Osnabrück Hand Eczema Severity Index (OHSI) and the levels of RAR and RXR expression (P < 0.001). CONCLUSION: Deficient retinoid receptor expression has a primary role in the pathogenesis, clinical phenotype, and severity of hand eczema and sheds light on the mechanism of action of retinoids in the treatment of chronic hand eczema.

Does the type and size of Amplatzer vascular plug affect the occlusion time of pulmonary arteriovenous malformations?

PURPOSE: Occlusion time (OT) is an important factor in the treatment of pulmonary arteriovenous malformations (PAVMs) since it can lead to serious complications. The purpose of our study is to calculate the OT of Amplatzer vascular plug (AVP, St Jude Medical), and correlate it to the type of the device used (AVP or AVP 2) and the percent of device oversizing. Technical success rates and complications were also recorded. METHODS: We retrospectively studied a total of 19 patients with 47 PAVMs who received percutaneous transcatheter embolization therapy using either AVP or AVP 2. We recorded the location, type, feeding artery diameter, AVP device used, and OT of each PAVM. We correlated the percent of device oversizing and the type of AVP with the OT. We also studied the rate of persistence of PAVM for both devices. RESULTS: Forty-six (98%) of the PAVMs were simple. Device diameters ranged from 4.0-16.0 mm with device oversizing ranging between 14% and 120%. There was a statistically significant difference in the OT of AVP and AVP 2 (3 min 54 s vs. 5 min 30 s, P = 0.030). There was a weak positive correlation between OT and device oversizing for AVP (r=0.246, P = 0.324) and AVP 2 (r=0.261, P = 0.240). No major complications were identified. Immediate technical success rate was 100%. CONCLUSION: The use of AVP 2, and increase in device oversizing were not associated with reduction in the OT of PAVMs. There was no reported difference in safety between the two devices, and no major complications were noted.