Naproxen-Induced Evans Syndrome.

Evans syndrome is an autoimmune disorder characterized by the simultaneous occurrence of autoimmune hemolytic anemia and immune thrombocytopenic purpura. It can further be classified as primary Evans syndrome when it occurs by itself, or secondary Evans syndrome when it is associated with other autoimmune and lymphoproliferative disorders. Corticosteroids and immunoglobulins are the first-line treatments for primary Evans syndrome, and subsequent options include other immunosuppressive medications. Medical literature provides little information about the triggers of primary Evans syndrome. Knowing such information, however, is essential to recognize, treat and prevent the recurrence of the disease effectively.  We report a 68-year-old female who presented with shortness of breath, cough, bruises, scleral icterus, and dark urine after several days of naproxen therapy for pain. Further workup noted direct antiglobulin test positive for IgG, anemia, and thrombocytopenia. Imaging studies showed deep venous thrombosis. She was diagnosed with Evans syndrome and improved following prompt treatment with corticosteroids, anticoagulants, blood transfusion therapies, and discontinuation of naproxen. The prognosis of Evans syndrome is poor, variable, and characterized by relapses. Early diagnosis and treatment are therefore associated with better prognosis.  This case is critical because it shines a light on one of the major causes of Evans syndrome, reports a practical approach to treating the condition, and paves the way for future research on Evans syndrome. This case is also the first reported naproxen-induced Evans syndrome in the world's literature.

A possible Guillain-Barré syndrome/transverse myelitis overlap syndrome after recent COVID-19.

Neurological manifestations are common in SARS-CoV-2 infection, including life-threatening acute muscle weakness, due to neuromuscular disorders such as acute transverse myelitis (TM) and Guillain-Barré syndrome (GBS). These syndromes can rarely coexist and present as an overlap syndrome. Here, we report a patient who developed acute symmetrical proximal lower limb weakness 5 days after diagnosis of COVID-19. GBS was diagnosed due to the presence of motor signs, albumin-cytological dissociation in cerebrospinal fluid examination and axonal damage according to nerve condition tests. However, abnormal areas on MRI of the thoracic spine and lack of improvement with intravenous immunoglobulin supported a diagnosis of TM. Therefore, a possible overlap between GBS and TM was established. To our knowledge, this is the third case report of GBS/TM overlap syndrome after COVID-19. The patient's full and rapid recovery with intravenous corticosteroids and plasmapheresis supports our diagnosis.

Pleural Effusion Secondary to Dasatinib Following Allogenic Hematopoietic Stem Cell Transplantation.

BACKGROUND Pleural effusions are frequently seen among patients with hematopoietic stem cell transplantation (HSCT). In the majority of cases, they are related to infections and volume overload. Medications have also been reported to cause pleural effusion in the general population, albeit very rarely. Dasatinib-induced pleural effusion has been reported in patients with chronic myeloid leukemia but not in those with HSCT. We here report a case of dasatinib-induced pleural effusion following HSCT for acute lymphocytic leukemia (ALL). The proposed mechanism of dasatinib-induced pleural effusion involves build-up of fluid due to an immune-mediated vascular insult. CASE REPORT A 72-year-old man who received HSCT for ALL was treated with dasatinib to prevent a recurrence. After 6 months, the patient was admitted to the hospital for pneumonia, which was observed as bilateral pleural effusion upon chest X-ray. After completing the antibiotics course, he developed recurrent pleural effusion during hospitalization. Repeated thoracentesis of the fluid revealed an exudative lymphocytic effusion with negative culture and cytology. Dasatinib was withdrawn and the pleural effusion resolved gradually. CONCLUSIONS In patients with dasatinib-induced pleural effusions following HCTS, withdrawal of the drug leads to symptom resolution, thereby avoiding unnecessary procedures. This case illustrates that dasatinib-induced pleural disease typically manifests with lymphocytic exudative fluid. Physicians should be aware that pleural effusion is a possible medication-related adverse effect, which may be missed in cases of infection in patients following HSCT.

Severe Rhabdomyolysis in a 35-Year-old Woman with COVID-19 due to SARS-CoV-2 Infection: A Case Report.

BACKGROUND Rhabdomyolysis is a skeletal muscle injury that has different etiologies and can be a manifestation of coronavirus disease 2019 (COVID-19). Because it is a life-threatening condition, rapid diagnosis is necessary to prevent acute complications. Diagnostic criteria for rhabdomyolysis are elevated serum creatine kinase, liver enzyme levels, and myalgia. Rhabdomyolysis can easily be missed in patients with COVID-19. Herein, we report the case of a female with rhabdomyolysis as a manifestation of acute COVID-19. CASE REPORT A 35-year-old female was found to have rhabdomyolysis associated with COVID-19. Her creatine kinase and liver enzyme levels were significantly elevated. Ringer's lactate infusion was administered at a controlled rate to treat the rhabdomyolysis along with boluses of normal saline, with close monitoring of her oxygen saturation and kidney function. The patient's creatine kinase and liver enzyme levels peaked on Day 2 and then decreased. Her medical condition improved, and she was discharged on Day 4. CONCLUSIONS Our case highlights the need to monitor the creatine kinase level of hospitalized patients with COVID-19. Fluid management can be challenging in patients with rhabdomyolysis due to COVID-19 because of the risk of fluid overload and acute respiratory distress syndrome. Clinicians should be aware that a significant elevation in liver enzyme levels and myalgia can be the presenting features of rhabdomyolysis in patients with COVID-19.