Glioblastoma Multiforme in a Patient with Multiple Myeloma: A Case Report and Literature Review.

INTRODUCTION: Lenalidomide is an immunomodulatory drug approved by the US Food and Drug Administration in 2006 for the treatment of multiple myeloma. In 2012, the Food and Drug Administration issued a statement warning physicians of the increased risk with lenalidomide treatment of the following secondary primary malignancies: Acute myelogenous leukemia, myelodysplastic syndromes, and Hodgkin lymphoma. The statement did not mention glioblastoma multiforme, a Grade 4 astrocytoma, or other high-grade astrocytomas that have been reported on rare occasions in the setting of multiple myeloma. CASE PRESENTATION: A 72-year-old man, who had been in complete remission from multiple myeloma for 1 year after treatment that included lenalidomide, presented with confusion, headache, nausea and vomiting, and recurrent falls. A magnetic resonance image of his brain revealed a mass that on stereotactic biopsy was found to be glioblastoma multiforme. DISCUSSION: We present the seventh reported case of high-grade astrocytoma as a second primary malignancy in multiple myeloma and the first reported occurrence of glioblastoma multiforme after the use of lenalidomide in multiple myeloma. This report adds to the pool of cases that reveal associations between use of lenalidomide and increased risk of developing secondary primary high-grade astrocytomas in multiple myeloma.

Undifferentiated Pleomorphic Sarcoma after Pirfenidone Use: A Case Report.

INTRODUCTION: Pirfenidone was approved in 2014 for the treatment of idiopathic pulmonary fibrosis. Pirfenidone inhibits several factors such as tissue growth factor-ß and platelet-derived growth factor, leading to decreased epithelial and fibroblast proliferation and collagen synthesis. The drug improves progression-free survival and is well tolerated, with minimal side effects. However, data on its long-term effects are lacking. CASE PRESENTATION: We present a rare case in which an undifferentiated pleomorphic sarcoma developed in a 59-year-old man with idiopathic pulmonary fibrosis who was treated with pirfenidone for more than a year. DISCUSSION: Undifferentiated pleomorphic sarcoma, also known as malignant fibrous histiocytoma, is a soft-tissue sarcoma arising from fibroblasts. The disease presents in the extremities and the trunk of elderly patients, and rarely in the retroperitoneum. Surgical excision is the mainstay of treatment; however, recurrence is common in the form of lung and lymph node metastases. In this report we review this rare malignancy and highlight the need for postmarketing longitudinal studies to determine additional adverse effects in patients with idiopathic pulmonary fibrosis who are on pirfenidone therapy.

Recognizing a Rare Phenomenon of Angiotensin-Converting Enzyme Inhibitors: Visceral Angioedema Presenting with Chronic Diarrhea-A Case Report.

INTRODUCTION: Peripheral angioedema of the face and upper airways is a well-known phenomenon of angiotensin-converting enzyme inhibitors occurring in only 0.1% to 0.7% of patients. We describe a case of the even less-common manifestation of visceral angioedema, which causes symptoms of chronic and intractable diarrhea. CASE PRESENTATION: A 68-year-old white woman presented with large-volume diarrhea, caused by visceral angioedema secondary to lisinopril therapy. Initial imaging studies were significant for distended small bowel loops, with subsequent unremarkable findings on colonoscopy and biopsy studies. After an exhaustive laboratory work-up, her diarrhea resolved only after the discontinuation of lisinopril. DISCUSSION: Use of angiotensin-converting enzyme inhibitors is increasing, making the recognition of visceral angioedema important in preventing significant morbidity and avoiding invasive and costly studies.

Pituitary apoplexy: a rare complication of leuprolide therapy in prostate cancer treatment.

Gonadotropin-releasing hormone agonists, used widely in the treatment of metastatic prostate cancer and hormone receptor-positive breast cancer, are associated with a rare but potentially fatal outcome of pituitary apoplexy (PA). An 85-year-old man presented with sudden onset of headache, left eye pain, sensitivity to light, nausea and vomiting. The symptoms started 4 hours after initiation of leuprolide therapy for treatment of recently diagnosed metastatic prostate carcinoma. Radiological imaging of the brain demonstrated a heterogeneously enlarged pituitary gland measuring 19×16×13 mm and T1-hyperintense signal compatible with pituitary haemorrhage. Hormone function tests were indicative of panhypopituitarism, confirming the diagnosis of PA. Due to age, the patient was started on hormonal replacement therapy and eventually symptoms improved.

A Severe Case of Cutaneous Adverse Drug Reaction Secondary to a Novice Drug: Idelalisib.

Phosphatidylinositol 3-kinase δ (PIK3δ) is a tyrosine kinase essential for B cell survival, making it an important target in the treatment of chronic lymphocytic leukemia. Idelalisib is an inhibitor of PIK3δ demonstrating initial success in disease response, but is now shown to have a decreased overall survival and life-threatening serious adverse events. The following is an unfortunate case of a grade III adverse skin reaction secondary to idelalisib with the likely complication of methicillin-resistant Staphylococcus aureus bacteremia.

An idiosyncratic reaction to clopidogrel.

Clopidogrel is an irreversible antiplatelet agent belonging to the thienopyridine group that acts to antagonize the adenosine diphosphate P2Y12 receptor on platelets. It thus inhibits the activation of platelet glycoprotein GPIIb/IIIa complex, which is essential for fibrinogen­platelet complex formation. Clopidogrel has widely replaced ticlopidine because of a much better clinical safety profile. Clopidogrel is a prodrug that requires hepatic activation to exert its antiplatelet effect. Hepatotoxicity with use of clopidogrel is a rare but clinically significant phenomenon. We report a case of clopidogrel-induced hepatotoxicity in an elderly white woman.

Opana ER abuse and thrombotic thrombocytopenic purpura (TTP)-like illness: a rising risk factor in illicit drug users.

We report the case of a 22 year-old-woman who presented with upper extremity cellulitis secondary to an infiltration of illicit intravenous drug use. She confessed to the intravenous use of Opana ER (an extended release oral formulation of oxymorphone) which is an opioid drug approved only for oral use. She was found to have clinical evidence of profound thrombotic microangiopathy which resulted due to the intravenous use of Opana ER. She showed full clinical improvement after withholding drug and supportive clinical care. Recent report of Opana ER intravenous abuse was published from Tennessee county and has now been increasingly recognised as one of the causes of thrombocytopenia which mimicks clinically as thrombotic thrombocytopenic purpura. Physicians should be aware of this association as the lack of familiarity to this can pose serious management dilemmas for our patients (especially the polysubstance abusers).

Peritoneal blastomycosis: a hidden mystery unfolds itself.

Blastomycosis is a disease caused by the fungus Blastomyces dermatitidis. Pulmonary blastomycosis is the most common form of blastomycosis. Disseminated blastomycosis is the fulminant form of the disease, with rare reports of peritoneal cavity involvement. We report a case of extensive form of the disease presenting initially as abdominal pain and mimicking peritoneal carcinomatosis.

Ataxia: a diagnostic perplexity and management dilemma.

A 79-year-old woman presented with lower extremity weakness and unsteadiness for 2 weeks. She was recently diagnosed with refractory atrial flutter and was prescribed amiodarone. Physical examination revealed signs of cerebellar dysfunction. Neuroimaging including CT and MRI were unremarkable. Her hospital course included the development of ventricular tachycardia necessitating increment in amiodarone dose. Laboratory studies were unremarkable except mild transaminitis. Other workup including the one for paraneoplastic neurological involvement was negative. The patient experienced worsening of ataxia requiring assistance with ambulation. In view of comprehensive routine negative work-up for ataxia, recent use of amiodarone and worsening of symptomatology with increase in its dosing, drug-induced neurotoxicity from amiodarone was suspected. Amiodarone dose was subsequently reduced and mexilitine was introduced as an additive antiarrhythmic therapy for ventricular tachycardia. In follow-up, the patient experienced significant improvement in her symptoms and was able to ambulate independently. She was subsequently discharged to short-term rehabilitation.

Prevalence and significance of electrocardiographic changes and side effect profile of regadenoson compared with adenosine during myocardial perfusion imaging.

BACKGROUND: Significance of electrocardiogram (EKG) changes associated with regadenoson as well as side effects compared to adenosine in a real world, unselected population is unknown. METHODS AND RESULTS: Three hundred ninety six consecutive patients undergoing either adenosine or regadenoson-based single-isotope (Technetium 99c) nuclear images were evaluated. A standard form documenting side effects was filled immediately following administration. The EKGs and nuclear scans were reviewed in a blinded-fashion. Commonest symptoms reported were flushing (64%), chest pain (36%) and dyspnea (36%). Flushing and chest pain were significantly more common with adenosine (73% vs. 57%, P < 0.01 and 53% vs. 47%, P = 0.06) and dyspnea more with regadenoson (40% vs. 31%, P = 0.05). Sixty (29%) patients carried a diagnosis of chronic bronchitis or asthma but only 4 (2 with each) required aminophylline. There was no significant correlation between chest pain induced by either agent or ischemia on nuclear imaging. EKG changes occurred infrequently (16% with regadenoson and 10% with adenosine), and had low sensitivity for detecting ischemia (7% for regadenoson and 11% for adenosine). CONCLUSIONS: EKG changes with adenosine and regadenoson occur infrequently and have low sensitivity for detecting ischemia. Chest pain is frequently induced by both, and is not predictive of ischemia on nuclear imaging.