Oxymorphone Induced Thrombotic Microangiopathy Mimicking Atypical Haemolytic Uremic Syndrome.

BACKGROUND: Atypical Haemolytic Uremic Syndrome (aHUS) is a rare life threatening entity characterized by thrombocytopenia, haemolytic anaemia and renal dysfunction. It is a thrombotic microangiopathy related to genetic mutations in the alternate complement pathway and has a distinct pathophysiology which makes it harder to distinguish from other microangiopathies. We present a case of a 25-year-old male patient with history of polysubstance abuse who presented with chest pain and dyspnoea. He admitted to using injectable oxymorphone (Opana) two weeks before presentation. Patient's vital signs were stable except for tachycardia and high blood pressure. On physical examination, epigastric tenderness and mild splenomegaly was appreciated. Urine Drug Screen was positive for oxycodone and opiates. Laboratory work up revealed haemolytic anaemia, thrombocytopenia and acute kidney injury. Extensive evaluation resulted in our impression of the disease being atypical haemolytic-uremic syndrome. He was managed with dialysis, intravenous steroids and plasmapheresis with improvement in his hematologic parameters.

Revascularization of traumatic renal artery dissection by endoluminal stenting: three cases.

Traumatic injury of renal arteries is rare and can induce renal dysfunction and hypertension. Management options include observation, nephrectomy, surgical repair, and, more recently, percutaneous angioplasty. We report three cases of renal artery thrombosis occurring in young multitrauma patients (mean age 28.7 years) treated with stenting. Immediate satisfactory results were obtained in all cases. Postprocedure anticoagulant and antiplatelet treatment were given according to associated contraindicating lesions. During follow-up, in-stent restenosis occurred in one patient and was treated successfully with a second stenting procedure. No renal dysfunction or hypertension was observed after 28.6 months follow-up. Percutaneous angioplasty is a valuable alternative to surgical treatment in selected patients.

Efficacy of amantadine on quality of life in patients with chronic hepatitis C treated with interferon-alpha and ribavirin: results from a randomized, placebo-controlled, double-blind trial.

AIM: The aim of this study was to investigate whether amantadine reduces deterioration of quality of life in patients with chronic hepatitis C during and after treatment with interferon-alpha (IFN-alpha) and ribavirin. PATIENTS AND METHODS: In this randomized, prospective, placebo-controlled, multicenter trial, previously untreated patients with chronic hepatitis C were treated with IFN-alpha plus ribavirin [17] and randomized for treatment with amantadine (200 mg/day, orally, n=136) or placebo (n=131). Quality of life was assessed with the 'Profile of Mood States' scale and the 'Everyday Life' questionnaire at baseline, treatment week (TW) 8, TW24, TW48, and at follow-up. RESULTS: Early during treatment at TW8, quality of life was not different between patients in the control and the amantadine group. At TW24, the control group but not the amantadine group, however, showed significant deterioration of the modalities depression, fatigue, and vigor compared with baseline. Especially, nonresponders in the amantadine group showed significantly lower deterioration of depression, anger, mind function, everyday life, and zest for life than those in the placebo group. After treatment, the beneficial effects of amantadine disappeared. CONCLUSION: The addition of amantadine to IFN-alpha plus ribavirin combination therapy may reduce deterioration of depression, fatigue, and vigor during treatment but does not affect quality of life after treatment.

Diffuse leukoencephalopathy in a 29-year-old male with hypertensive emergency.

Severe hypertension is associated with multiple symptoms that reflect the end-organ damage effect of rapidly increasing blood pressure. Encephalopathy is a manifestation of the clinical spectrum of hypertensive emergencies. Hypertensive encephalopathy was initially described as part of the posterior reversible encephalopathy syndrome, which mostly involved the parieto-occipital white matter of the brain. A more detailed review of this syndrome reveals many cases where the brain abnormalities are distributed in a more random pattern. We describe a case of diffuse leukoencephalopthy in a young male who presented with altered mental status, ataxia, and blurred vision. This is the most diffuse brain involvement ever described in hypertensive statuses.

Cytokine imbalance in acute coronary syndrome.

The excessive mortality of coronary heart disease is attributed primarily to rupture and thrombotic transformation of the atherosclerotic plaque. Inflammation plays a critical role in plaque destabilization and vulnerability. Inflammation is not confined to the culprit segment but is convincingly widespread in the coronary and remote vascular beds. Systemic inflammatory, thrombotic and hemodynamic factors are relevant to the pathological and clinical outcome. In addition to their fundamental role in thrombosis, there is ample evidence that platelets contribute significantly to promoting plaque inflammation. A new paradigm of unbalanced cytokine-mediated inflammation is emerging, providing diagnostic and therapeutic opportunity for intervention. Amplifying intrinsic anti-inflammatory mechanisms constitutes attractive avenues for future investigation.

[Erythema gyratum repens: drug reaction following azathioprine administration in a patient with type I autoimmune hepatitis]. / Erythema gyratum repens: Arzneimittelreaktion nach Azathioprin bei einer Patientin mit Autoimmunhepatitis Typ I.

BACKGROUND: Erythema gyratum repens is a rare, clinically specific, and distinctive paraneoplastic syndrome. CASE REPORT: A case of erythema gyratum repens in a 76-year-old woman with autoimmune hepatitis type I treated with glucocorticoids is reported. Within 3 weeks of supplementary azathioprine treatment, the patient reported gastrointestinal discomfort and developed an erythema gyratum repens confined to the abdomen, thighs and knees. Azathioprine medication was stopped and the dermatologic features resolved completely after a period of 1 week. Absence of any demonstrable underlying malignancy was confirmed by different tests. Molecular diagnosis detected heterozygous G460A and A719G transitions in the thiopurine methyltransferase (TPMT) gene. 18 month later, complete remission on maintenance therapy (prednisone 7.5 mg) was observed with further absence of malignancy. CONCLUSION: This is the first report of an erythema gyratum repens in association with azathioprine treatment in an autoimmune hepatitis type I patient with proven common polymorphism in the TPMT gene.

Multiple pulmonary nodules: a complex case of Wegener's granulomatosis.

Wegener's granulomatosis is a granulomatous vasculitis that can present with a wide spectrum of clinical manifestations. This disease entity predominantly affects the respiratory tract and the kidneys. Two forms of Wegener's granulomatosis have been recognized: systemic and limited. It has not been established if the two forms represent separate disease entities or different stages of the same condition. In the limited form of Wegener's granulomatosis there is no immediate threat to the function of vital organs and there is no evidence of glomerulonephritis. Environmental factors that could serve as triggers for the activation of Wegener's granulomatosis have not been clearly defined. We report a case of a 78-year old male who was found to have bilateral pulmonary nodules on pre-operative chest X-ray and was diagnosed with the limited form of Wegener's granulomatosis. The patient developed Clostridium difficile infection, and shortly after that active glomerulonephritis, a manifestation of systemic Wegener's granulomatosis.

A rare case of spinal dural arteriovenous fistula.

Spinal dural arteriovenous fistula (SDAVF) is a rare vascular malformation of the spine. Only a limited number of cases of SDAVF have been reported in the current literature. We describe the case of a 74 year old male who presented with gradually progressive bilateral lower extremity weakness and bladder dysfunction and was subsequently diagnosed with SDAVF affecting both the thoracic and lumbar spine. The patient later underwent embolization with some improvement in his neurologic symptoms.

Rhabdomyolysis associated with phentermine.

PURPOSE: A case of rhabdomyolysis associated with the use of phentermine is reported. SUMMARY: A 32-year-old Caucasian man with a recent history of strenuous exercise sought treatment for significant back, shoulder, and radiating inguinal pain. The patient's home medications included the following, administered orally: esomeprazole, levothyroxine, irbesartan- hydrochlorothiazide, metoprolol succinate, metoclopramide, dicyclomine, oxycodone-acetaminophen, and oxycodone extended-release. He also used testosterone topical gel. During the hospital stay, it was discovered that the patient had been taking phentermine hydrochloride 37.5 mg twice daily, double the recommended dosage, for approximately one week before and on the day his symptoms started. His initial laboratory test values were as follows: troponin I, 17.46 ng/mL; creatine kinase (CK), 114,383 units/L; CK-MB, 745.5 ng/mL; and serum creatinine (SCr), 2.8 mg/dL. The patient was diagnosed with rhabdomyolysis of the left deltoid muscle, shoulder, posterior scapula, and upper thorax and with secondary acute renal failure. The patient's urine output was initially poor and rapidly declined to anuria on day 2 of admission. He received i.v. hydration with 0.45% sodium chloride at an initial rate of 200 mL/hr with 75 meq/L of sodium bicarbonate for urinary alkalinization. He did not require renal replacement therapy, and his urine output began to improve to 0.5 mL/kg/hr on hospital day 5 and was 1.42 mL/kg/hr before discharge. Use of the Naranjo et al. adverse-event probability scale revealed that phentermine was the probable cause of the patient's rhabdomyolysis. CONCLUSION: A 32-year-old man developed rhabdomyolysis after ingesting double the recommended dosage of phentermine for a week in addition to engaging in strenuous activity.

Extended treatment duration for hepatitis C virus type 1: comparing 48 versus 72 weeks of peginterferon-alfa-2a plus ribavirin.

BACKGROUND & AIMS: The treatment of patients infected with hepatitis C virus (HCV) type 1 remains a challenge necessitating innovative strategies to improve treatment outcome. The extension of treatment duration beyond 48 weeks is one possible strategy to address this problem. METHODS: The efficacy and safety of 48 weeks (group A, N = 230) vs 72 weeks (group B, N = 225) of treatment with pegylated-interferon-alfa-2a (180 microg/wk) plus ribavirin (800 mg/day) were studied in treatment-naive patients with HCV type 1 infection. On-treatment and sustained virologic response (SVR) 24 weeks after stopping treatment was assessed by qualitative reverse-transcription polymerase chain reaction (sensitivity 50 IU/mL). RESULTS: Overall, no significant differences could be observed in the treatment outcome between both groups. End-of-treatment and SVR rates in groups A and B were 71% vs 63% and 53% vs 54%, respectively. Patients with undetectable HCV-RNA levels already at weeks 4 and 12 had excellent SVR rates ranging from 76% to 84% regardless of treatment group, whereas patients shown to be still HCV-RNA positive at week 12 achieved significantly higher SVR rates when treated for 72 instead of 48 weeks (29% vs 17%, P = .040). A particular benefit from extended treatment duration was seen in patients with low-level viremia (<6000 IU/mL) at week 12. The frequency and intensity of adverse events was similar between the 2 groups. CONCLUSIONS: Extended treatment duration generally is not recommended in HCV type 1 infection and should be reserved only for patients with slow virologic response defined as HCV-RNA positive at week 12 but negative at week 24.

Triple therapy with amantadine in treatment-naive patients with chronic hepatitis C: a placebo-controlled trial.

The antiviral efficacy of amantadine in patients with chronic hepatitis C is controversial. In this randomized, prospective, placebo-controlled, multicenter trial, triple therapy with interferon alfa (IFN-alpha)-2a plus ribavirin and amantadine (amantadine group) was compared with combination therapy IFN-alpha plus ribavirin (control group). Four hundred previously untreated patients with histologically proven chronic hepatitis C were randomly allocated to treatment with amantadine sulphate (100 mg twice daily orally) or a matched placebo together with IFN-alpha induction plus ribavirin (1,000-1,200 mg/day orally) for 48 weeks. The primary end point was sustained virologic response (SVR) defined as undetectable serum hepatitis C virus (HCV) RNA (<100 copies/mL) 24 weeks after the end of treatment. SVR was observed in 52% of the amantadine group and in 43.5% of the control group (P =.11). Among patients with HCV genotype 1 infection, the corresponding SVR rates were 39% and 31%, respectively. The virologic on-treatment response rate in week 24 was significantly higher in the amantadine group as compared with the control group (70% vs. 59%, respectively, P =.016). This beneficial effect was mainly related to HCV type 1-infected patients (63% vs. 47%, respectively, P =.012). Independent factors associated with SVR, according to multiple logistic regression analysis, were amantadine treatment, low baseline HCV RNA, platelet counts (>/=250/nL), pretreatment ALT quotient >/=3, and GGT level (<28 U/L) as well as HCV genotypes other than 1. In conclusion, although we could not demonstrate a significant advantage of the triple regimen in univariate analysis, multivariate analysis offers arguments that amantadine should be considered as a potential anti-HCV drug in future studies.