Baffling Case of a Patient With History of Lupus in a COVID-19 Pandemic.

Systemic lupus erythematosus (SLE) is an autoimmune disease with a myriad of clinical presentations and periodic flares. We present a case of a young lady with a history of SLE who presented with constitutional symptoms 1 week after starting Isoniazid and Rifampin for treatment of latent TB. Her presentation shared similarities with several diseases including TB lymphadenitis, SLE flare, Kikuchi-Fujimoto Disease (KFD) and hemophagocytic lymphohistiocytosis (HLH) posing a diagnostic dilemma. Additionally, she presented not long after the onset of the global COVID-19 pandemic, further expanding the differential diagnosis. She was ultimately diagnosed with a severe SLE flare caused by rifampin induced suppression of the CYP3A4 system, thereby reducing the therapeutic efficacy of steroids. This case highlights the deadly potential of drug-drug interactions, especially in patients with autoimmune conditions.

Hyponatraemia due to hypothyroidism: a rare side effect from pomalidomide.

Pomalidomide is an immunomodulatory drug used for relapsed and refractory multiple myeloma (RRMM). Hypothyroidism is an uncommon side effect of pomalidomide. We present a 70-year-old male patient with RRMM on daratumumab, pomalidomide and dexamethasone, who presented with 2 weeks of fatigue. Laboratory values showed sodium of 120 mEq/L, plasma osmolarity of 256 mOsm/kg, urine osmolarity of 648 mOsm/kg and urine sodium of 93 mEq/L. Adrenocorticotropic hormone (ACTH) stimulation test was within normal limits. Thyroid-stimulating hormone (TSH) was 88.6 IU/mL (0.380-4.700 IU/mL), total triiodothyronine (TT3) <21 ng/mL (0.8-2 ng/mL), free thyroxine (fT4) 0.10 ng/dL (0.93-1.70 ng/dL) and free triiodothyronine (fT3) <0.5 pg/mL (2.3-4.2 pg/mL). Antithyroid peroxidase antibody was 726 IU/mL (<9 IU/mL). TSH 1 year ago was 2.88 IU/mL and TT3 was 1.06 ng/mL. He was started on levothyroxine with improvement in his symptoms, sodium level and thyroid functions. The most likely culprit was pomalidomide. Checking thyroid functions before and periodically while on pomalidomide is important in screening for this possible side effect.

Incidental findings on computed tomography angiography in patients evaluated for pulmonary embolism.

RATIONALE: To investigate how often computed tomography (CT) pulmonary angiography contributes to establishing a diagnosis in patients presenting to the emergency department and how it performs compared to chest radiograph. OBJECTIVES: The objective of this study was to measure the ability to identify a diagnosis and to investigate the prevalence and significance of incidental findings in patients evaluated with computed tomography pulmonary angiography in the emergency department. METHODS: All adult patients evaluated with CT angiography over a 2-year period (January 1, 2011 to December 31, 2012) were included in the analysis. A total of 641 records were identified. Chest radiographs and CT angiography reports were reviewed to determine whether they could provide a diagnosis in patients without pulmonary embolism (PE). Studies negative for PE were stratified into three categories according to significance: type I prompted immediate action, type II required follow up, and type III had findings of limited significance. MEASUREMENTS AND MAIN RESULTS: CT angiography identified a diagnosis in 22.46% of the patient population and in 14.31% of patients without PE. In patients who had CT angiography with chest radiograph, diagnoses were provided in 14.01 and 9.86% of patients, respectively. When analysis was isolated to patients with low probability for PE, CT angiography provided a diagnosis in 20% and chest radiography in 10.23% of patients. The majority of missed cases represented infiltrates too small to be detected by radiography and were believed to represent lung infections by the interpreting radiologist. Among studies negative for PE, 15% were type I, 17.07% were type II, 48.1% were type III, and the rest were normal. CONCLUSIONS: CT angiography is superior to chest radiography at providing a diagnosis in patients investigated for PE, even when no PE is present. However, in patients at low risk for PE, the clinical benefit of the additional diagnoses is questionable.

CT pulmonary angiography utilization in the emergency department: diagnostic yield and adherence to current guidelines.

The aim is to investigate the patterns of computed tomography pulmonary angiography (CTPA) use and adherence to current guidelines. Medical records of patients investigated with CTPA for pulmonary embolism (PE) in a single academic hospital from January 2011 until December 2012 were reviewed. Wells scores were calculated retrospectively by researchers blinded to the results of the CTPA. "Avoidable imaging" was defined as imaging performed against current recommendations of the European Society of Cardiology or the PIOPED investigation group. A total of 646 patients underwent testing; 61 cases of PE were diagnosed (9.4%). Potentially avoidable imaging was performed in 49.5% and 71.5% of patients, depending on the criteria used; 11.5% of imaging studies were performed in low-risk patients with negative D-dimer assays. There is evidence of CTPA overuse and D-dimer underuse. Adherence to guidelines and appropriate use of D-dimer assay might reduce avoidable imaging and ionizing radiation exposure.

Tamoxifen-associated Budd-Chiari syndrome complicated by heparin-induced thrombocytopenia and thrombosis: a case report and literature review.

We reported a rare case of Budd-Chiari syndrome (BCS) associated with tamoxifen use, which was later complicated by heparin-induced thrombocytopenia and thrombosis (HITT). The patient was a 44 year-old woman with a medical history of lobular carcinoma in situ, who had been on tamoxifen for 2 years, presented with abdominal pain and distention. Imaging studies followed by a liver biopsy confirmed the diagnosis of BCS. On extensive work-up, the patient was found to have an unclassified myeloproliferative disorder with positive JAK-2 V617 mutation. After discontinuing tamoxifen, the patient was started on intravenous heparin. However, later in the course, she developed HITT. Myeloproliferative disorder, in conjunction with tamoxifen, predisposed the patient to be highly thrombophilic resulting in BCS. HITT was found to be relatively common in BCS. Anticoagulation and blood count need to be carefully monitored, and the possibility of HITT emergence in these patients should always be kept in mind.