Autoimmune Hemolytic Anemia Associated With Myelodysplastic Syndrome: A Case Report.

Myelodysplastic syndrome (MDS) represents a spectrum of myeloid disorders occasionally linked to autoimmune diseases. Here, we present a case of a 60-year-old man demonstrating an unusual coexistence of MDS with warm-autoantibody autoimmune hemolytic anemia (wAIHA). Diagnostic evaluation, including positive direct antiglobulin testing, confirmed the autoimmune etiology of his anemia despite his low-risk MDS classification. Prompt initiation of prednisone therapy resulted in significant hematological and clinical improvement, allowing for a conservative management approach without transfusion requirements. This case underscores the importance of identifying the relationship between wAIHA and MDS, particularly in low-risk scenarios. Moreover, these findings suggest the efficacy of corticosteroids in managing autoimmune anemia in the context of concomitant wAIHA and MDS.

Diagnosis of Angioimmunoblastic T Cell Lymphoma After Receiving First Dose of Pfizer/BioNTech (BNT162b2) Vaccine: A Case Report.

Pfizer/BioNTech (BNT162b2) is a messenger RNA (mRNA) vaccine that is highly effective in preventing the most severe outcomes of COVID-19 infection. Nucleoside-modified severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccines induce effective stimulation of T follicular helper (TFH) cells, leading to a robust germinal center B cell response. Side effects from the BNT162b2 vaccination, including significant lymphadenopathy, have been reported previously. Here, we present a case of angioimmunoblastic lymphoma (AITL), a rare, peripheral T-cell lymphoma with RHOA-G17v-mutated gene developing in a patient following BNT162B2 vaccine with a plausible explanation. A 60-year-old Asian female received her first dose of Pfizer BNT162B2 mRNA vaccine in August 2021. Right after her vaccination, she developed right axillary lymphadenopathy. She received her second vaccine dose in September 2021. Thereafter, she developed lymph node (LN) enlargement in her neck and groin. She underwent left posterior cervical and left groin LN excisional biopsy in April 2022 due to persistent palpable lymphadenopathy. Biopsy results then demonstrated benign follicular hyperplasia. For progressive B symptoms, a right axillary LN biopsy was done, which demonstrated AITL, with molecular studies revealing mutation in TET-2, IDH-2, and RHOA-G17v genes. Progression of AITL following BNT162B2 mRNA vaccine is limited in literature. Our case demonstrates a plausible correlation between the diagnosis of AITL following mRNA vaccination due to the malignant transformation of the TFH cells in patients who have a predisposing mutation of RHOA-17v. Given the rarity of AITL and the heterogeneity of molecular findings, more studies are needed to establish such an association.

Clinical Response of Nuberol Forte® for Pain Management With Musculoskeletal Conditions in Routine Pakistani Practice (NFORTE-EFFECT).

Background Musculoskeletal pain is the most common complaint presented to the health practitioner. It is well-known that untreated or under-treated pain can have a significant negative impact on an individual's quality of life (QoL). Objectives The current study aimed to assess the clinical response of Nuberol Forte® (paracetamol 650 mg + orphenadrine 50 mg) to musculoskeletal pain in routine Pakistani practice and its impact on improving the patient's QoL. Methods A prospective, observational multicenter study (NFORT-EFFECT: Safety & Efficacy of Nuberol Forte in Pain Management). Three hundred ninety-nine patients with known prescreened musculoskeletal pain were recruited from 10 major healthcare facilities across six (6) major cities of Pakistan, as per the inclusion/exclusion criteria. After the baseline visit (Visit 1), the patients were followed up one to two weeks (Visit 2) after the treatment as per the physician's discretion. Data were collected using the Case Report Form (CRF) designed for the study, and adverse events (AEs) were also monitored to assess drug safety. Pain intensity was assessed through a visual analog scale (VAS), and QoL was assessed using the Muscle and Joint Measure (MJM) scale. Results Out of 399 enrolled patients, 49.4% were males and 50.6% were females with a mean age of 47.24 ± 14.20 years. Most patients were presented with knee osteoarthritis (OA), i.e., 148 (38%), followed by backache 70 (18.2%). A significant reduction in the mean pain score was observed after treatment with the combination of paracetamol and orphenadrine (p<0.05). Furthermore, an overall improvement in the patient's QoL was also observed. During the study, only 10 patients reported mild adverse events (AEs), namely, dryness of the mouth, dizziness, gastric irritation, tachycardia, restlessness, etc. Conclusion The combination of paracetamol and orphenadrine (Nuberol Forte) exhibited effective pain management among patients with musculoskeletal conditions and improved their QoL.

Pulmonary Tumor Embolism Microangiopathy: A Cause of Respiratory Failure in Advanced Malignancy.

INTRODUCTION: Etiologies of acute respiratory failure in breast cancer patients are diverse (acute respiratory distress syndrome, acute interstitial pneumonia, pulmonary fibrosis, radiation pneumonitis, malignant infiltration). Pulmonary tumor embolism microangiopathy (PTEM) is a rare complication of advanced cancer that often presents as respiratory failure, pulmonary hypertension, right heart failure, and sudden death. Breast cancer is the most common primary cause of PTEM. It takes an aggressive course and presents with a challenge to diagnose and eventually manage. Here, we present the case of PTEM in a woman with advanced breast cancer. CASE SUMMARY: A 53-year-old female presented to the emergency department with shortness of breath. Her past medical history was significant for HER-2 positive breast cancer with metastatic lesions in the brain, spine, and liver. In the emergency department (ED), the patient was tachycardic, tachypneic, hypoxic, hypotensive and hyperthermic. Laboratory results showed anemia, severe thrombocytopenia, alkalemia, hypoxia with decreased levels of arterial oxygen tension, decreased arterial carbon dioxide with a compensatory metabolic acidosis as well as grossly elevated transaminases, elevated D-Dimer, and multiple inflammatory markers. CT angiography and echocardiogram were performed but they failed to establish a definite diagnosis. The patient was admitted to the intensive care unit due to progressive acute hypoxic respiratory failure despite being tested negative for pulmonary embolism. Despite resuscitative measures with intravenous diuretics, multiple transfusions as well as antibiotics, she remained tachypneic with respiratory rate of 40/min and oxygen saturation between 70-80 percent. She passed away a few hours later. No autopsy was performed. CONCLUSION: We recommend that if a patient with established malignancy presents with deteriorating lung function whereby there is evidence of progressive dyspnea and consolidation on radiographs, empirical antimicrobial treatment has failed to show improvement and thromboembolism has been ruled out, PTEM should be considered for early diagnosis.

Sugar, Spice, and Bleeding.

Brodifacoum (BDF), otherwise known as superwarfarin, is a long-acting anticoagulant rodenticide (LAAR) which acts as a vitamin K antagonist. Much like warfarin, BDF's mechanism of action is to irreversibly inhibit the enzyme vitamin K epoxide reductase, thus reducing the recycling of vitamin K and, therefore, reducing the activation of clotting factors two, seven, nine, and 10. Although BDF is usually found in rodenticides, it has been recently used as an additive in synthetic cannabinoids. We present a case of a young male with a history of synthetic cannabinoid use who presented with hematuria and epistaxis and was ultimately found to have BDF poisoning.