From skin to spontaneous lysis: A case of spontaneous tumor lysis syndrome in metastatic melanoma.

Tumor lysis syndrome is a life-threatening complication that often occurs after administration of cytotoxic therapy, but rarely occurs spontaneously without chemotherapy. This vignette describes a 59-year-old male with known extensive metastatic melanoma who presented to the hospital with spontaneous tumor lysis syndrome. Most spontaneous tumor lysis cases occur in patients with acute leukemias and aggressive lymphomas; however, this rare case depicts a patient with melanoma developing tumor lysis before the administration of chemotherapy.

Retrospective comparison of low molecular weight heparin vs. warfarin vs. oral Xa inhibitors for the prevention of recurrent venous thromboembolism in oncology patients: The Re-CLOT study.

Background There is increasing evidence indicating oral factor Xa inhibitors can be used for secondary prevention of venous thromboembolism. Studies are needed to compare oral factor Xa inhibitors, low molecular weight heparins, and warfarin in the oncology population. The purpose of this study is to evaluate the recurrent venous thromboembolism incidence in oncology patients utilizing oral Xa inhibitors, low molecular weight heparins, or warfarin. Methods Using retrospectively collected data, we compared the recurrent venous thromboembolism incidence in oncology patients taking rivaroxaban/apixaban, enoxaparin, or warfarin with at least three months of follow-up. Patients were included if they had an active cancer, venous thromboembolism, and taking warfarin, enoxaparin, or rivaroxaban/apixaban. The primary endpoint was the first episode of recurrent venous thromboembolism at three months. Secondary endpoints included recurrent venous thromboembolism after six months, major bleeding, and mortality. Results Of 127 venous thromboembolism patients, 48 received rivaroxaban or apixaban, 23 received enoxaparin, and 56 received warfarin. The three most common cancer diagnoses were lung (21%), colorectal (14%), and breast (14%). There was no difference in venous thromboembolism recurrence at three months between the rivaroxaban/apixaban (0%), warfarin (3.6%), and the enoxaparin cohorts (4.4%) (p = 0.8319). Major bleeding at three months was only seen in one patient in the enoxaparin arm (4.2%). Mortality at three months was 0%, 3.6%, and 17.4% in the rivaroxaban/apixaban, warfarin, and enoxaparin cohorts, respectively. Conclusion The results of this retrospective study suggest that oral factor Xa inhibitors are potential options for cancer patients with venous thromboembolism. However, randomized, controlled trials are needed to confirm these results.

Severe palmar-plantar erythrodysesthesia and aplasia in an adult undergoing re-induction treatment with high-dose cytarabine for acute myelogenous leukemia: a possible drug interaction between posaconazole and cytarabine.

High-dose cytarabine is recommended for re-induction chemotherapy in patients less than 60 years of age with acute myelogenous leukemia. This case describes a patient receiving high-dose cytarabine for re-induction and subsequently developed tingling and numbness in her hands and feet followed by severe pain, swelling, and erythema consistent with a diagnosis of palmar-plantar erythrodysesthesia. Furthermore, the patient's hemoglobin, platelets, and neutrophils did not recover after over 30 days post high-dose cytarabine. The patient was concurrently receiving posaconazole for fungal prophylaxis which was initiated after the induction therapy. We speculate that posaconazole may inhibit the cytarabine efflux through P-glycoprotein inhibition leading to the patient's palmar-plantar erythrodysesthesia and subsequent aplasia. Future pharmacokinetic studies need to be conducted to ascertain if posaconazole does influence the pharmacokinetics of cytarabine.

Ecthyma gangrenosum associated with Proteus bacteremia.

Ecthyma gangrenosum is an exceedingly rare dermatologic complication of bacteremia or fungemia in immunocompromised patients. The lesions may be single or multiple and may occur anywhere on the body. We present a case of ecthyma gangrenosum with atypical organisms and risk factors resulting in delayed diagnosis of both the condition and the underlying infectious process that caused it. Despite the atypical findings, the diagnosis was confirmed by biopsy and tissue culture.

Nitrous oxide-induced vitamin B12 deficiency.

Nitrous oxide is a gas that is odorless, colorless, and has a sweet taste at room temperature. Nitrous oxide has several uses, including in surgery and dentistry (referred to as "laughing gas"), in automotive racing, and in aerosol spray propellants. The aerosol spray propellants that typically use nitrous oxide are whipped cream canisters and cooking sprays. Unfortunately, these over-the-counter household items are a source of nitrous oxide that can be used for recreational use. The most popular is the use of industrial-grade canisters having the slang term "whippets." The nitrous oxide can be extracted by pushing the nozzle down slightly to the side and catching the released gas with a balloon. The contents of the balloon can then be directly inhaled, giving an instant feeling of euphoria. This is not a benign means to achieve a euphoric state but can cause severe nitrous oxide-induced B12 deficiency, which is presented in this case report.

Rheumatoid meningitis associated with infliximab.

We present a patient who had rheumatoid meningitis while on infliximab, a tumor necrosis factor alpha (TNF-α) inhibitor, which initially presented as transient ischemic attacks. Although our patient had been stable on infliximab for several years, her neurologic symptoms improved when her infliximab was held due to active infection and then recurred after reinitiation of therapy. Rheumatoid meningitis is exceedingly rare; however, there have been several other reports of rheumatoid meningitis developing in patients on TNF-α inhibitor therapy.

Change in prescription habits after federal rescheduling of hydrocodone combination products.

Nationally, health care providers wrote 259 million prescriptions for narcotic analgesics in 2012, or roughly one bottle of narcotics per US adult (1). In an effort to combat this ever-growing problem, the Drug Enforcement Administration changed the schedule of hydrocodone combination products from schedule III to schedule II on October 6, 2014. Fourteen Baylor Scott & White pharmacies encompassing a 200-mile radius in Central Texas were queried for prescription information on hydrocodone/acetaminophen, morphine, codeine/acetaminophen, and tramadol before and after the rescheduling to evaluate trends in prescription drug usage. While the rescheduling of hydrocodone combination products resulted in a reduced number of prescriptions and the total quantity dispensed of both the hydrocodone/acetaminophen 5/325 mg (Norco 5/325) and 10/325 mg (Norco 10/325) formulations, this was offset by a dramatic increase in alternative narcotic analgesics such as tramadol, codeine/acetaminophen 30/300 mg (Tylenol #3), and codeine/acetaminophen 60/300 mg (Tylenol #4), which do not have schedule II requirements. Additionally, there was no significant reduction in total pain medication prescribed after converting all agents to morphine equivalents.