Response to Sorafenib After Sunitinib-Induced Acute Heart Failure in a Patient with Metastatic Renal Cell Carcinoma: Case Report and Review of the Literature

Cardiotoxicity is an emerging concern with a new class of drugs known as targeted agents, which include trastuzumab and sunitinib. Sunitinib is a small molecule that inhibits multiple tyrosine kinase receptors. This drug was approved by the United States Food and Drug Administration in 2006 for the treatment of clear cell metastatic renal cell carcinoma and advanced gastrointestinal stromal tumors. We describe a 65-year-old woman who was treated with sunitinib for metastatic clear cell renal cell carcinoma. After 5 months of therapy, she developed acute heart failure requiring hospitalization; sunitinib was immediately discontinued. The patient had classic symptoms of heart failure, including pleural effusion. An echocardiogram revealed a left ventricular ejection fraction of 30%. She received standard treatment for heart failure, including a β-blocker, an angiotensin-converting enzyme inhibitor, and diuretics. Within 1 month, the patient's symptoms resolved, and subsequent cardiac evaluation showed that her left ventricular ejection fraction returned to normal. According to the Common Terminology Criteria for Adverse Events developed by the National Cancer Institute, her cardiac event associated with sunitinib was defined as grade III toxicity. One month later, sorafenib, another tyrosine kinase inhibitor, was started with the aim of continuing her previous response to sunitinib. After 7 months of sorafenib therapy, the patient had no evidence of heart failure, and her condition was responding to treatment. Clinicians should be aware that sunitinib-induced heart failure occurs occultly and that many—but not all—cases resolve with discontinuation of the drug. Use of sorafenib after sunitinib-induced heart failure appears to be safe and effective, which suggests that cardiotoxicity is not a general class effect of the tyrosine kinase inhibitors.     

Acute Poisoning with Neonicotinoid Insecticides: A Case Report and Literature Review

Neonicotinoids are a new class of insecticides widely applied for crop protection. These insecticides act as agonists at nicotinic acetylcholine receptors, which cause insect paralysis and death. The high specificity for receptors in insects was considered to possess highly selective toxicity to insects and relative sparing of mammals. However, an increasing number of cases of acute neonicotinoid poisoning have been reported in recent years. We reported a man who developed respiratory failure and shock after ingestion of neonicotinoid insecticide. A detailed literature review found that respiratory, cardiovascular and certain neurological presentations are warning signs of severe neonicotinoid intoxication. The amounts of ingested neonicotinoid insecticide and the plasma neonicotinoid concentration are not useful guides for the management of intoxicated patients. Supportive treatment and decontamination are the practical methods for the management of all neonicotinoid‐poisoned patients.     

肾脏原发性恶性淋巴瘤1例报告并文献复习

目的 探讨肾脏原发性恶性淋巴瘤的临床、病理特点和诊治方法.方法 报告1例肾脏原发性恶性淋巴瘤的临床资料,结合文献复习讨论.患者,女,50岁,主诉为左侧腰部不适2个月.CT示左肾中下极7.0cm×6.5cm软组织影,密度均匀.结果 行根治性肾切除.术后病理诊断为非霍奇金弥漫性B细胞淋巴瘤.术后行CHOP方案化疗6疗程,随访29个月,患者无瘤存活.结论 肾脏原发性恶性淋巴瘤临床罕见,确诊需依赖病理组织学检查,治疗方法主要是单纯化疗或根治性肾切除加化疗和/或放疗.     

Acute 1,2,3‐Trichloropane Poisoning: A Case Report and Literature Review

Abstract: 1,2,3‐Trichloropropane is widely used in industrial and agricultural production. However 1,2,3‐trichloropropane poisoning has been rarely encountered in clinical practices. Here, a 45‐year‐old farmer who suffered fulminant hepatic failure due to ingestion of 1,2,3‐trichloropropane has been reported and literature about 1,2,3‐trichloropane poisoning has been reviewed. For this case, reduced glutathione, vitamin K, pantoprazole were infused intravenously, and transfusion of blood plasma, platelets and red blood cells were carried out. Unfortunately, the patient’s family gave up treatment and they left the hospital with the patient because of the low chance of recovery 20 hr after admission. Based on blood toxicology screening, patient history and rapid deterioration of the patient, the cause of fulminant hepatic failure was determined to be acute intoxication of 1,2,3‐trichloropropane by unintentional toxicity. 1,2,3‐trichloropropane has histopathological toxic effects on many organs and this toxic effect occurs within a short period after ingestion, with liver as the major affected organ.     

星形母细胞瘤1例并文献复习

目的探讨星形母细胞瘤的病理形态学特点、诊断及鉴别诊断。方法应用光镜观察及免疫组织化学方法对1例星形母细胞瘤进行临床病理分析,并复习文献。结果星形母细胞瘤病变常表现为特征性的乳头状结构,瘤细胞围绕在血管周围形成假菊形团结构,细胞突起短而粗;血管出现进行性的胶原化和玻璃。免疫组织化学瘤细胞GFAP,S-100,VIM,EMA反应阳性,Syn,NF反应阴性。结论星形母细胞瘤是一种罕见的胶质肿瘤,组织学起源未定,目前根据组织学特征分为低级别和高级别两组,低级别星形母细胞瘤预后好于高级别星形母细胞瘤。     

阿昔洛韦致急性肾功能衰竭及不合理用药分析

通过研究国内外文献资料及我国和世界卫生组织不良反应数据库数据,分析阿昔洛韦致急性肾功能衰竭的发生情况、临床特征、发病机制和不合理用药现状,强调合理用药、开展药物警戒工作的重要性。     

急性梗阻性肾衰抗生素脑病诊治体会并相关文献复习

目的:分析急性梗阻性肾衰出现抗生素脑病病例临床表现、特点及有效治疗护理过程,进一步提高对该疾病的认识,提高治疗效果。方法:回顾性分析自2010年1月~2015年1月发生在某院的9例急性梗阻性肾衰出现抗生素脑病病例资料,总结分析发病原因、临床表现共性、个性及主要治疗及护理措施。结果:治疗后观察组肾小球滤过率显著升高(P<0.05),且恢复为正常范围,同时收缩压与舒张压与治疗前相比明显降低(P<0.05),且治疗后恢复正常。结论:急性梗阻性肾衰抗生素脑病临床相比慢性肾衰尿毒症抗生素脑病更加少见,易误诊漏诊,早期发现立即停药立即血液透析及精心护理是最有效的治疗方法,患者预后一般较好。     

Thrombolytic-Associated Cholesterol Emboli Syndrome: Case Report and Literature Review

Thrombolytics can cause cholesterol embolization syndrome (CES). This adverse effect has received less attention than other risks of thrombolytic therapy, such as systemic bleeding and hemorrhage, with only sporadic reports of CES in the literature. Risk factors have not been consistently identified and emphasized; therefore, occurrence of CES after thrombolysis remains difficult to predict, it results in substantial morbidity and mortality, and it lacks effective pharmacologic treatment. Heightened awareness of the disorder can aid in its correct identification and reporting.     

Propofol-Induced Dystonia: A Case Report and a Review of the Literature

Abstract

Purpose: To report a case of acute dystonia that appears related to the use of propofol in a patient with epilepsy and to report its successful management by diphenhydramine.

Clinical features: A 16-year-old white male with a history of left posterior temporal neocortical onset seizures underwent epilepsy surgery. Preoperative antiepileptic maintenance medications included phenytoin and lamictal. A limited posterior temporal resection (topectomy) was performed, and propofol (Diprivan®) was used to supplement the local anesthesia. During the surgery the patient developed prominent orofacial and extremity dystonia with forced, maximal mouth opening during speech and leg jerking. The movements were associated with agitation and confusion. Following surgery administration of intravenous fos-phenytoin resulted in an exacerbation of the movement disorder. The patient responded favorably to intravenous diphenhydramine therapy; the involuntary movements and confusion abated completely over a 3-hour period. The reaction was classified as moderate in severity, possible in probability and nonpreventable.

Conclusion: Propofol therapy has the potential to induce dystonia that can be controlled by diphenhydramine. The risk of dystonia may be increased in individuals also receiving phenytoin.     

4-Aminopyridine Toxicity: a Case Report and Review of the Literature

Introduction

4-Aminopyridine (4-AP) selectively blocks voltage-gated potassium channels, prolongs the action potential, increases calcium influx, and subsequently, enhances interneuronal and neuromuscular synaptic transmission. This medication has been studied and used in many disease processes hallmarked by poor neuronal transmission in both the central and peripheral nervous systems including: multiple sclerosis (MS), spinal cord injuries (SCI), botulism, Lambert-Eaton syndrome, and myasthenia gravis. It has also been postulated as a potential treatment of verapamil toxicity and reversal agent for anesthesia-induced neuromuscular blockade. To date, there have been limited reports of either intentional or accidental 4-AP toxicity in humans. Both a case of a patient with 4-AP toxicity and review of the literature are discussed, highlighting commonalities observed in overdose.

Case Report

A 37-year-old man with progressive MS presented with diaphoresis, delirium, agitation, and choreathetoid movements after a presumed 4-AP overdose. 4-AP concentration at 6 h was 140 ng/mL. With aggressive benzodiazepine administration and intubation, he recovered uneventfully.

Discussion

The commonalities associated with 4-AP toxicity conforms to what is known about its mechanism of action combining cholinergic features including diaphoresis, altered mental status, and seizures with dopamine-related movement abnormalities including tremor, choreoathetosis, and dystonia. Management of patients poisoned by 4-AP centers around good supportive care with definitive airway management and controlling CNS hyperexcitability aggressively with gamma-aminobutyric acid agonist agents. Adjunctive use of dopamine antagonists for extrapyramidal effects after sedation is a treatment possibility. As 4-aminopyridine recently received Federal Drug Administration approval for the treatment of ambulation in patients with MS, physicians should be keenly aware of its presentation, mechanism of action, and management in overdose.     

婴幼儿纤维性错构瘤一例并文献复习

目的 探讨婴幼儿纤维性错构瘤的病理学特征,以提高对该病的认识.方法 对1例婴幼儿纤维性错构瘤行手术切除及组织病理学和免疫组化观察,并复习相关文献.结果 巨检肿物与周围组织分界较清,镜下肿瘤由3种组织成分呈器官样排列,未见核分裂象.免疫组化:肿瘤组织内SMA梭形细胞、S-100脂肪细胞、CD34幼稚梭形细胞均阳性,β-catenin阴性.结论 婴幼儿纤维性错构瘤是一种罕见的软组织病变,预后良好.     

Warfarin Resistance Associated with Intravenous Lipid Administration: Discussion of Propofol and Review of the Literature

Intravenous lipids are often required for parenteral nutritional (PN) support in critically ill patients and are administered with continuous sedation if patients are receiving propofol, which contains soybean oil 10% as an emulsified preparation. High-dose propofol infusion was associated with reversal of enteral and intravenous warfarin anticoagulation in a 39-year-old woman with severe Crohn's disease. Despite increasing the daily dose of warfarin to 30 mg, anticoagulation was not achieved until propofol was discontinued. Reversal of anticoagulation recurred when PN support was supplemented with Liposyn II 20%. Lipid emulsions may interfere pharmacodynamically with warfarin activity by enhancing the production of clotting factors, facilitating platelet aggregation, or supplying vitamin K. They also may facilitate warfarin binding to albumin. Until further information regarding the mechanism of interference is elucidated, heparin therapy should be considered for initial anticoagulation in patients with intestinal absorptive deficiencies who receive high-dose lipid emulsions and require reliable anticoagulation. If warfarin is given, the international normalized ratio should be monitored daily to ensure adequate anticoagulation.     

Bradycardia After Intravenous Ondansetron with Asystole on Rechallenge: A Case Report

Purpose:

There have been 3 published reports (4 cases) of symptomatic sinus bradycardia occurring after intravenous (IV) administration of the selective 5-hydroxytryptamine 3 (5-HT₃) receptor antagonist ondansetron. We report a fifth case in which the patient developed asystole after rechallenge with ondansetron.

Summary:

A 36-year-old pregnant patient with no cardiac history, status post cerclage for cervical insufficiency, experienced nausea in the post ambulatory care unit after administration of morphine and indomethacin for pain. After IV administration of ondansetron, the patient’s heart rate decreased to the 40s and improved spontaneously. The patient experienced a second episode of nausea, another dose of ondansetron was administered, and the patient went into asystole. Advanced cardiac life support measures were initiated and chest compressions were conducted for 3 minutes with return of spontaneous circulation. The patient was monitored overnight with no development of new cardiac arrhythmias and was discharged from the hospital in stable condition.

Conclusions:

Sinus bradycardia after IV administration of ondansetron was observed in a 36-year-old pregnant patient status post cerclage. On rechallenge, the patient went into asystole. This case report adds to the available literature regarding ondansetron-induced cardiac arrhythmias and the possibility of asystole upon rechallenge.     

儿童嗜酸粒细胞性膀胱炎1例报告并文献复习

目的:探讨儿童嗜酸粒细胞性膀胱炎临床特征及诊治要点。方法:回顾分析1 例嗜酸粒细胞性膀胱炎患儿的临床资料,并进行诊断性治疗,随访患儿病情转归情况。并复习嗜酸粒细胞性膀胱炎相关文献。结果:患儿,女,7 岁,临床表现为尿频、尿急、尿痛及夜尿增多,血常规提示嗜酸粒细胞明显升高,给予糖皮质激素及抗过敏治疗后,患儿临床症状缓解,复查血常规提示嗜酸粒细胞降低。结论:对于临床以尿路刺激症状为主要表现结合嗜酸粒细胞升高患儿需警惕儿童嗜酸粒细胞性膀胱炎。     

1例肉碱棕榈酰转移酶2缺乏症报道并文献复习

目的：总结肉碱棕榈酰转移酶2（CPT2）缺乏症的诊治经验。方法：回顾性分析1例CPT2缺乏症患儿的临床资料和基因检测结果,并复习相关文献。结果：患儿,1岁7个月,第二次发病,两次临床表现主要为横纹肌溶解综合征,基因检测CPT2基因提示突变c.338C>T（p.S113L）和c.1711c>A（p.P571T）,c.338C>T（p.S113L）来自母亲,c.1711c>A（p.P571T）来自父亲,最终确诊为CPT2缺乏症。结论：反复发作的较小年龄横纹肌溶解综合征患儿需警惕遗传代谢病如CPT2缺乏症,通过基因检测做到早发现、早预防。     

Phenytoin-Induced Purple Glove Syndrome: A Case Report and Review of the Literature

Objective:

To present a case report and literature review of phenytoin-induced purple glove syndrome (PGS).

Case summary:

A 54-year-old African American male presented to our hospital’s emergency department (ED) following a seizure episode, cardiac arrest, and loss of consciousness. On arrival to the ED, the patient’s total phenytoin level was subtherapeutic at 4.1 mcg/mL and his corrected total phenytoin level was subtherapeutic at 5.1 mcg/mL. In the ED, the patient received a loading dose of intravenous (IV) phenytoin 1,000 mg once via the left cephalic vein, at a rate of 50 mg/min, and was admitted to the medicine service. A day following IV phenytoin administration, a nurse noticed an IV fluid infiltration on the skin tissue around the left cephalic vein. The area appeared dark blue and purple in color, swollen, erythematous, and warm to touch. An ultrasound of the left upper extremity was performed and revealed subcutaneous fluid collection without evidence of thrombosis.

Discussion:

The Naranjo Adverse Drug Reaction Probability Scale assigned a score of 7, indicating phenytoin as the probable cause of purple glove syndrome (PGS). The patient’s PGS was managed with a combination of dry dressing material, left forearm elevation, collagenase topical cream, 0.1% IV bupivacaine, and IV fentanyl. The patient’s injury was resolving at the time of discharge to a rehabilitation facility.

Conclusion:

PGS is a rare complication of IV phenytoin therapy. The risk of PGS for this patient may have been abated by decreasing the phenytoin infusion rate from 50 mg/min to less than 25 mg/min.     

儿童Kimura病1例报道并文献复习

目的:分析儿童Kimura病的临床特点,探讨儿童Kimura病的诊治方法及预后。方法:对我院2014年收治的1例儿童Kimura病进行报道,同时检索2005-2015年的中国医院知识总库(CHKD),收集资料完整的7 例儿童Kimura病报道,对这8例Kimura病患儿的临床表现、实验室检查、治疗及预后进行综合分析。结果:儿童Kimura病主要表现为头颈部肿块、淋巴结肿大、大涎腺侵犯,外周血嗜酸粒细胞增多、血清IgE水平升高,病灶边界不清无包膜,激素治疗有效,但容易复发。结论:Kimura病是一种罕见的、慢性的、病因不明的慢性炎性疾病,儿童Kimura病更加罕见,常表现为头颈部肿块,伴淋巴结肿大及大涎腺侵犯,手术、激素治疗有效,但容易复发。