Cyclophosphamide, Bortezomib, and Dexamethasone and Severe Systolic Heart Failure: A Case Report.

Multiple myeloma (MM) is a neoplastic proliferation of plasma cells in bone marrow. Pharmacotherapy for the management of patients with MM includes drug classes like proteasome inhibitors, monoclonal antibodies, immunomodulators, alkylating agents, steroids, etc. We present a case of new-onset heart failure with reduced ejection fraction (HFrEF) in a patient with previously normal ejection fraction after treatment with a cyclophosphamide, bortezomib, and dexamethasone (CyBorD) chemotherapeutic regimen. An echocardiogram done after the completion of nine cycles of chemotherapy in a period of about 4.5 months showed severely decreased left ventricular systolic function with an ejection fraction of only 15-20% and grade I diastolic dysfunction. Cardiac catheterization showed no angiographic evidence of vessel occlusion or epicardial disease. HFrEF was managed with the initiation of guideline-directed medical therapy with cardiology clinic follow-up, and the patient was discharged with a plan to start a lenalidomide-based chemotherapeutic regimen with oncology clinic follow-up. It is, therefore, imperative to perform a thorough cardiovascular assessment before initiation of chemotherapy, complemented by periodic and recurrent assessments of cardiovascular function during and after completion of the treatment course, for early detection and prevention of potentially severe cardiovascular toxicities in patients with MM.

Intravenous Hydration and Associated Outcomes in Patients With Sickle Cell Disease Admitted With Vaso-Occlusive Crises: A Systematic Review.

Acute painful vaso-occlusive crisis (VOC) is the common presentation of sickle cell disease (SCD) leading to emergency room visits, admissions, morbidity, mortality, and negative impacts on quality of life. Among various treatment approaches commonly employed to manage the condition, intravenous (IV) hydration is also frequently used in emergency and inpatient settings. Although helpful to overcome dehydration, IV hydration often leads to adverse outcomes like fluid overload, pulmonary edema, increased length of stay, transfer to intensive care unit, new oxygen requirement, etc. Small-scale retrospective studies are conducted to study the outcomes of IV hydration but have failed to conclusively demonstrate its benefits as well as choice of IV fluids, rate of IV fluid replacement, etc. We conduct this review as an attempt to summarize the available evidence on the role and utility of IV hydration in sickle cell crises along with reported adverse outcomes.

Unmasking the Silent Threat: Cefepime-Induced Thrombocytopenia.

Cefepime, a commonly prescribed fourth-generation cephalosporin, is well-known for its broad-spectrum antibacterial activity. While adverse drug reactions associated with cefepime are well documented, thrombocytopenia as a rare complication has gained attention due to its potential severity. Symptomatic patients present with purpura (bruising), petechiae (small red or purple spots on the skin), and mucosal bleeding. Drug-induced thrombocytopenia can be initiated by myelosuppression by halting platelet formation in the bone marrow or by a drug-induced immune thrombocytopenia reaction. We present a case of a 71-year-old male who experienced thrombocytopenia secondary to cefepime use. We further discussed the underlying mechanisms of cefepime-induced thrombocytopenia, highlighting the need for increased vigilance in monitoring platelet counts during cefepime administration. This case underscores the importance of recognizing and managing this uncommon but potentially life-threatening adverse reaction in clinical practice.

Type II Heparin-Induced Thrombocytopenia: An Underrecognized Cause of Dialysis Catheter Dysfunction - A Case Report.

Heparin-induced thrombocytopenia (HIT) is categorized into type 1 and type 2. It causes a decrease in platelet count during or shortly after exposure to heparin. Type 1 is mild and has a non-immune mechanism. Type 2 is a hypercoagulable state resulting from anti-heparin platelet factor 4 (PF4) IgG antibodies. These antibodies cause the activation of endothelium and thrombin generation. Type 2 HIT is complicated by life-threatening thromboembolic events such as deep venous thrombosis, pulmonary embolism, and myocardial infarction. HIT remains an under-recognized cause of dialysis catheter dysfunction and thrombosis. We present a case of a 66-year-old male with recurrent dialysis catheter thrombosis secondary to Type 2 HIT. Avoiding heparin-based dialysis or switching to non-heparin-based anticoagulation or peritoneal dialysis are the possible management strategies for such patients.

A Rare Case of Valproic Acid Toxicity Requiring Hemodialysis.

Valproic acid poisoning can have mild to fatal consequences depending on its body concentration. There are rare case reports and barely any known controlled studies on the use of hemodialysis as a last treatment resort. We report a rare valproic acid poisoning case at One Brooklyn Health/Interfaith campus, New York City, warranting intubation and hemodialysis. The patient is a 47-year-old male with a past medical history of seizure disorder, polysubstance use disorder, schizophrenia, and gastroesophageal reflux disease (GERD) who was brought to the medical emergency department (ED) for intentional valproic acid overdose with 60 tablets of his prescribed home Depakote DR 500 mg (~30 g). The patient's other outpatient medications included valproic acid, trazodone, acetaminophen, famotidine, fluoxetine, folic acid, hydrocortisone-aloe, multivitamin, nicotine polacrilex, and thiamine. The patient's initial blood tests showed high valproic acid, ammonia, ethanol, and lactate. About six hours after ED admission, the patient became somnolent, desaturated to 74% on a non-rebreather oxygen mask, warranting intubation and hemodialysis after noticing persistently high serum concentrations of valproic acid. The relatively low molecular weight (144 Daltons) and low volume of distribution of valproic acid suggest a potential benefit from hemodialysis, especially at a serum concentration of >850 mg/L or in the event of a shock. In this patient, mentation and stability status were improved after hemodialysis. Hemodialysis appears to be the last treatment resort for severe valproic acid poisoning.

A Rare Presentation of Levetiracetam-Induced Torsades De Pointes.

Torsades de pointes occurs in the presence of a prolonged QTc interval, which has many congenital and acquired causes. Levetiracetam is a widely used anti-epileptic medication secondary to its favorable safety profile. We present a rare case of a 59-year-old male who developed torsades de pointes and cardiac arrest after levetiracetam administration. To our knowledge, there is only one other case report documenting torsades de pointes after levetiracetam administration, and our case report will be the first documenting cardiac arrest after levetiracetam administration.

Myocardial Bridging: Two Different Clinical Presentations in Young Males Involving Left Anterior Descending Coronary Artery.

Myocardial bridging is a rare anatomical variant that can lead to detrimental cardiac consequences when undiagnosed and untreated. This rare variant can induce anginal-type symptoms due to disrupted blood flow to the myocardium during systole. The patients presented in this report of two cases had previously undiagnosed myocardial bridging of the left anterior descending artery, however clinically, they presented quite differently. Here we present two cases discussing the course of diagnosis and treatment of myocardial bridging of these two patients. The goal of this case report is to highlight the significant cardiovascular injuries that can be a result of undiagnosed myocardial bridging.

Overlapping Symptoms of COVID-19 and Giant Cell Arteritis: The Need for a Higher Degree of Suspicion for Diagnostic Differentiation.

Giant cell arteritis (GCA) is a large cell vasculitis that can present with a plethora of symptoms affecting several different systems. Before the COVID-19 pandemic, diagnosis of GCA was straightforward since the list of differential diagnoses for this disease was relatively short. However, the development of a SARS-CoV-2 viral infection challenges this standard. COVID-19 is a viral illness that also can present with similar vascular symptoms as GCS and creates a substantial inflammatory reaction, similar to most vasculitis. We present a case of a patient who had developed GCA after recovering from a COVID-19 viral illness. This is a rare presentation of GCA in the setting of COVID-19, and recognition of the nuanced differences between the two diseases may significantly change a patient's prognosis if not detected early.

Prevalence of Ruptured Intracranial Aneurysms in a Tertiary Care Hospital of Nepal.

INTRODUCTION: Intracranial aneurysms affect 3-8 percent of the world's population, with ruptured aneurysms being the most common cause of subarachnoid hemorrhage. The sensitivity of Computed Tomography Angiogram in diagnosing intracranial aneurysm is 97%. The aim of our study is to find out the prevalence of ruptured intracranial aneurysms among all the admitted cases encountered in our hospital. METHODS: A descriptive cross-sectional study was done at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences from 2016 to 2018. Convenience sampling method was done. In order to detect the site and size of aneurysms, 16 slice Siemens Computed Tomography with Computed Tomography angiogram was used. Ethical approval was obtained from the Institutional Review Committee at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences. Based on demographic data and computed tomography angiography findings, various morphometric parameters along with demographic parameters were considered for the study. RESULTS: Among 10,856 cases, prevalence of ruptured intracranial aneurysms were found in 42 (0.386%) [Confidence Interval= 0.395 to 0.377]. Among 42 cases, Middle Cerebral Artery aneurysm was present on 16 (39.02%) followed by Anterior Communicating Artery on 14 (34.14%), then Posterior Communicating Artery on 5 (12.19%). The largest neck and dome size were seen in basilar tip aneurysm with size of 11mm and 8mm respectively. The most common type was Fischer grade 4. CONCLUSIONS: The prevalence of ruptured intracranial aneursyms were found to be higher as compared to the other international studies.