Publications by authors named "Satish Maharaj"

46 Publications

Coagulopathy following Crotaliπae snakebites in northeast Florida.

Blood Coagul Fibrinolysis 2022 Jun 10;33(4):220-223. Epub 2022 Jan 10.

Division of Hematology & Oncology, Department of Medicine, Hematology & Oncology, University of Louisville, Louisville, Kentucky.

Effects of Crotalinae envenomation vary by geographical areas and research into coagulopathy and effects of antivenom are needed to optimize management. This was a single-center retrospective review with testing on presentation and 4 h after; antivenom administration was noted and data analyzed overall and comparing envenomations. One hundred and nineteen snakebites evaluated with 59 identified as Crotalinae and half receiving antivenom. PT/aPTT was elevated in 20% of water moccasin/copperhead and 21% of rattlesnake bites. DIC-like syndrome occurred in 8% water moccasin/copperhead and 6% rattlesnake bites. Antivenom did not seem to correct PT or aPTT at 4 h follow-up in most cases. Thrombotic microangiopathy was not seen. Coagulopathy was prevalent affecting one in five patients in this cohort and does seem to persist at short interval follow-up, even in those receiving antivenom. We support guidelines recommending clinical monitoring and serial coagulation profiles in such cases. Blood Coagul Fibrinolysis 30:000 - 000 Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
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http://dx.doi.org/10.1097/MBC.0000000000001123DOI Listing
June 2022

Procalcitonin as a diagnostic marker for infection in sickle cell disease.

Expert Rev Hematol 2022 Jun 23;15(6):559-564. Epub 2022 May 23.

Department of Hematology & Oncology, University of Louisville, Louisville, KY, USA.

Background: Patients with sickle cell disease (SCD) are at increased risks of infection. Fever often occurs with vaso-occlusive crisis (VOC), posing a diagnostic challenge in SCD. Procalcitonin (PCT) is an infectious biomarker validated in the general population but with limited data on use in SCD.

Methods: We performed a retrospective single-center study (n = 145) with primary objective of assessing ability of PCT to differentiate infection from VOC in SCD presenting with fever. Subgroups included confirmed bacterial infection (CBI), suspected bacterial infection, viral infection, and VOC. A secondary objective examined the association of PCT with acute chest syndrome. Clinical characteristics and data were collected and analyzed to assess the diagnostic performance of PCT and associated variables.

Results:   Of the cohort, 16% had CBI and 8% had viral infection. PCT was able to discriminate CBI from viral infection [AUC = 0.89 (95%CI, 0.78-0.99)] and VOC [AUC = 0.87 (95%CI, 0.78-0.97)]. PCT had an association with ACS but poor diagnostic performance [AUC = 0.69 (95% CI, 0.54-0.84)].

Conclusion: PCT has utility in distinguishing confirmed bacterial infection from VOC or viral infection and is a promising biomarker when investigating fever in SCD.
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http://dx.doi.org/10.1080/17474086.2022.2079490DOI Listing
June 2022

Sinonasal renal cell-like adenocarcinoma arising in von Hippel Lindau (VHL) syndrome.

Oral Oncol 2022 02 5;125:105705. Epub 2022 Jan 5.

Hematology & Oncology, University of Louisville, Louisville, KY, United States.

Sinonasal renal cell-like adenocarcinoma (SNRCLA) is a rare and relatively novel diagnosis. Hereditary and somatic genomic signatures are not well defined in this disease. We report the case of a 35-year-old African-American male with von Hippel Lindau (VHL) syndrome who developed SNRCLA. He underwent surgical resection followed by adjuvant radiation and has no recurrence one year from diagnosis. A review of the literature yielded two similar cases in the setting of VHL. In our case with associated VHL syndrome, next generation sequencing detected MST1R mutation, a possible driver. SNRCLA is an emerging tumor associated with VHL syndrome and it is hoped that future studies shed light on the underlying biology of this unique tumor.
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http://dx.doi.org/10.1016/j.oraloncology.2021.105705DOI Listing
February 2022

Novel splicing (c.6529-1G>T) and missense (c.1667G>A) mutations causing factor V deficiency.

Blood Coagul Fibrinolysis 2021 Jul;32(5):344-348

Mayo Comprehensive Hemophilia Center, Special Coagulation and Molecular Hematopathology Laboratories, Mayo Clinic, Rochester, Minnesota, USA.

Congenital factor V deficiency (FVD) is a rare bleeding disorder. In this study, we investigated the genetic basis in an African American patient with factor V activity 3%. Custom sequence capture and targeted next-generation (NGS) sequencing of the F5 gene were undertaken followed by PCR and Sanger sequencing. Two novel variants were identified. In silico analyses correlated clinically with the patient's factor V activity and hemorrhagic tendency. A review of the literature regarding these genomic alterations is presented. We described two novel mutations causing moderate FVD. The first, Chr1:g.169483698C>A with cDNA change (F5):c.6529-1G>T, occurred in a conserved nucleotide at the canonical acceptor splice site of intron 24. The second, Chr1:g.169515775C>T with cDNA change (F5):c.1667G>A, was a missense variant of exon 11, affecting a highly conserved amino acid in the A2 domain. Further research into the mechanisms of F5 mutations leading to FVD and residual factor V expression are needed.
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http://dx.doi.org/10.1097/MBC.0000000000001036DOI Listing
July 2021

Thrombotic thrombocytopenic purpura (TTP) response following COVID-19 infection: Implications for the ADAMTS-13-von Willebrand factor axis.

J Thromb Haemost 2021 04;19(4):1130-1132

Department of Hematology & Oncology, University of Louisville, Louisville, Kentucky, USA.

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http://dx.doi.org/10.1111/jth.15230DOI Listing
April 2021

Breast Implant-Associated CD30 Negative Peripheral T-Cell Lymphoma, NOS.

Hemasphere 2021 Jan 9;5(1):e507. Epub 2020 Dec 9.

Department of Hematology & Oncology, University of Louisville, Kentucky, USA.

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http://dx.doi.org/10.1097/HS9.0000000000000507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732339PMC
January 2021

Spur-cell anemia.

Cleve Clin J Med 2020 11 2;87(11):649-650. Epub 2020 Nov 2.

James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY.

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http://dx.doi.org/10.3949/ccjm.87a.20044DOI Listing
November 2020

Left ventricular thrombi in malignancy: A therapeutic dilemma.

Heart Lung 2021 Jan - Feb;50(1):231. Epub 2020 Oct 21.

Hematology/Oncology Fellow PGY-5, Department of Oncology, University of Louisville, KY, United States. Electronic address:

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http://dx.doi.org/10.1016/j.hrtlng.2020.10.001DOI Listing
April 2021

In Reply: Trousseau sign and syndrome: Erroneous terms.

Cleve Clin J Med 2020 10 1;87(10):586. Epub 2020 Oct 1.

James Graham Brown Cancer Center, University of Louisville School of Medicine Louisville, KY.

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http://dx.doi.org/10.3949/ccjm.87c.10003DOI Listing
October 2020

Mönckeberg medial sclerosis.

Cleve Clin J Med 2020 06 30;87(7):396-397. Epub 2020 Jun 30.

Department of Medicine, University of Louisville School of Medicine, Louisville, KY

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http://dx.doi.org/10.3949/ccjm.87a.19085DOI Listing
June 2020

Renal artery stenosis presenting as preeclampsia.

Clin Hypertens 2020 1;26. Epub 2020 Apr 1.

1Department of Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, USA.

Background: Renal artery stenosis is a notorious cause of secondary hypertension which classically presents as chronic refractory hypertension, recurrent flash pulmonary edema or renal insufficiency after initiation of an angiotensin converting enzyme inhibitor. Rarely, there have been reported cases of pregnant patients presenting with new onset or superimposed preeclampsia secondary to renovascular hypertension. In this subset of patients, renovascular hypertension carries significantly higher risks including obstetric, fetal and medical emergencies and death. Prompt treatment is required. However, the teratogenic risks of radiological investigations and antihypertensive medications limit diagnostic and management options thus posing quite a dilemma.

Case Presentation: A 38-year-old female, at 33 weeks of gestation, was hospitalized for preeclampsia with severe features. A viable neonate had been expeditiously delivered yet the patient's post-partum blood pressures remained severely elevated despite multi-class anti-hypertensive therapy. Renal artery dopplers revealed greater than 60% stenosis of the proximal left renal artery and at least 60% stenosis of the right renal artery. Renal angiography showed 50% stenosis of the left proximal renal artery for which balloon angioplasty and stenting was performed. The right renal artery demonstrated less than 50% stenosis with an insignificant hemodynamic gradient, thus was not stented. Following revascularization, the patient's blood pressure improved within 48 h, on dual oral antihypertensive therapy.

Conclusions: Preeclampsia that is refractory to multi-drug antihypertensive therapy should raise suspicion for renal artery stenosis. Suspected patients can be screened safely with Doppler ultrasonography which can be then followed by angiography. Even if renal artery stenosis does not seem severe, early renal revascularization may be considered in patients with severe preeclampsia who do not respond to antihypertensive management.
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http://dx.doi.org/10.1186/s40885-020-00140-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110679PMC
April 2020

Trousseau syndrome.

Cleve Clin J Med 2020 Apr;87(4):199-200

James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY.

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http://dx.doi.org/10.3949/ccjm.87a.19086DOI Listing
April 2020

Metastatic ductal adenocarcinoma of the breast presenting with pericardial effusion-Challenges in the diagnosis of breast cancer.

Clin Case Rep 2019 Dec 24;7(12):2384-2387. Epub 2019 Oct 24.

Division of Rheumatology and Clinical Immunology Department of Medicine University of Florida College of Medicine Jacksonville FL USA.

Breast cancer is a common entity that can be difficult to diagnose. This case demonstrates the limitations of breast cancer diagnostics. Particularly, how the available imaging techniques and even biopsy can potentially miss a malignancy. It exemplifies the role immunohistochemistry staining plays in the diagnosis of cancers of unclear origin.
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http://dx.doi.org/10.1002/ccr3.2497DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6935662PMC
December 2019

Sarcoidosis presenting with facial swelling (Heerfordt syndrome).

Clin Case Rep 2018 Oct 5;6(10):2023-2024. Epub 2018 Sep 5.

Department of Internal Medicine University of Florida College of Medicine Jacksonville Florida.

Sarcoidosis is one of the "great masqueraders" of medicine and can present with atypical facial swelling. Imaging and biopsy confirm the diagnosis.
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http://dx.doi.org/10.1002/ccr3.1741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6186866PMC
October 2018

Anti-PF4/heparin antibodies are increased in hospitalized patients with bacterial sepsis.

Thromb Res 2018 11 27;171:111-113. Epub 2018 Sep 27.

Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA.

Heparin-induced thrombocytopenia (HIT) is caused by antibodies targeting platelet factor 4 (PF4)/heparin complexes. The immune response leading to HIT remains perplexing with many paradoxes. Unlike other drug induced reactions, anti-PF4/heparin antibody generation does not follow the classic immunologic response. Research in murine models suggests that that there is close interplay among infection, PF4 and the immune system. We hypothesized there would be a relatively higher prevalence of anti-PF4/heparin antibodies in patients hospitalized for sepsis. We retrospectively examined anti-PF4/heparin antibody testing in 200 such patients. This included patients who had sepsis with bacteremia (n = 57), sepsis with fungemia (n = 7) and sepsis without bacteremia or fungemia (n = 136). For comparison, data from 50 patients without sepsis during the same time period was used. Results confirmed that patients hospitalized with sepsis have higher anti-PF4/heparin antibody levels. The groups of patients having sepsis with bacteremia, and sepsis without bacteremia, had significantly higher OD than the control group without sepsis (p < 0.05). There was no significant difference between Gram negative and Gram positive bacteremia and antibody levels. This suggests that bacterial cell wall components of both classes have similar antigenicity. Interestingly, patients who had sepsis with fungemia had much lower antibody levels compared to those with sepsis and bacteremia, and sepsis without bacteremia or fungemia. Despite the small sample size for fungemia, this difference trended strongly towards statistical significance (p = 0.05). It would be interesting to investigate this further in a larger study or using in vitro studies. In summary, there is an increased prevalence of anti-PF4/heparin antibodies in patients hospitalized with bacterial but not fungal sepsis. These results indicate that bacterial infection has a role to play in preimmunization leading to anti-PF4/heparin antibody generation.
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http://dx.doi.org/10.1016/j.thromres.2018.09.060DOI Listing
November 2018

Temporality of heparin-induced antibodies: a retrospective study in outpatients undergoing hemodialysis on unfractionated heparin.

Exp Hematol Oncol 2018 14;7:23. Epub 2018 Sep 14.

1Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Florida College of Medicine-Jacksonville, UF Health Jacksonville, 653 W 8th St, Jacksonville, FL 32209 USA.

Background: Heparin-induced antibodies (HIA) are responsible for causing heparin-induced thrombocytopenia and thrombosis. Research has shown that the temporality of heparin-induced antibodies does not follow the classic immunologic response. The immunobiology of HIA generation remains unclear with varying in vitro and in vivo data. Outpatients undergoing hemodialysis (HD) are exposed to heparin chronically. The HIA immune response can therefore be investigated in vivo in this population.

Methods: We examined the time between the start of HD using unfractionated heparin and HIA levels in 212 outpatients during a 6-year period. Antibodies were detected on enzyme-linked immunosorbent assay. HIA levels were analyzed to determine significance of the trend over time. HIA subgroups were also analyzed for correlation with subsequent thrombotic events and platelet count during follow up.

Results: Overall, the HIA response in HD was found to peak early with waning antibody response despite continued exposure to heparin. The peak prevalence of a strong immune response (optical density > 1.000) was early and short lived, while weaker immune response (optical density 0.400-1.000) persisted for the first 6 months then declined. The mean follow-up time per patient was 2.3 ± 1.4 years. Despite circulating HIA, including high titers, no patients developed HIT in this sample. There was no association between HIA and thrombocytopenia. There was increased incidence of thrombosis in patients with strong HIA compared to other groups, but this did not achieve statistical significance.

Conclusions: The data suggest a significant temporal pattern of HIA in outpatients undergoing HD using unfractionated heparin. Positive HIA was not found to be significantly associated with thrombocytopenia or thrombosis risk in these patients. However, while not achieving statistical significance, subsequent thrombotic events occurred most frequently in the strong positive HIA group (optical density > 1.000). Further research into HIA and risk of thrombosis in this population is needed.
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http://dx.doi.org/10.1186/s40164-018-0115-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137914PMC
September 2018

Coexistent Breast Cancer and Essential Thrombocythemia: How We Addressed the Therapeutic Challenges.

Case Rep Hematol 2018 12;2018:2080185. Epub 2018 Aug 12.

Department of Hematology and Oncology, University of Florida College of Medicine, Jacksonville, FL 32209, USA.

Essential thrombocythemia (ET) occurring with breast cancer is uncommon; the therapeutic approach varies and poses a challenge. A 65-year-old female presented to us after being diagnosed with hormone positive, HER2-negative infiltrating ductal carcinoma. She had a platelet count of 600 thou/cu mm. Her JAK2 mutation was positive. Bone marrow biopsy showed increased megakaryocytes. She was diagnosed with ET in the setting of breast cancer. She underwent breast conservation surgery after which aspirin was resumed. Anticipating thrombocytopenia during chemotherapy and given the absence of data combining hydroxyurea with standard chemotherapy used for breast cancer, we felt it prudent to delay cytoreductive therapy for her ET until after completion of breast cancer treatment. Her average platelet count during chemotherapy was 480 thou/cu mm with the lowest being 377 thou/cu mm. Her platelet count remained at goal between 300 and 350 thou/cu mm after four months of hydroxyurea.
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http://dx.doi.org/10.1155/2018/2080185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109582PMC
August 2018

Flashes of light and floaters: an unusual presentation of urothelial carcinoma.

BMJ Case Rep 2018 Aug 29;2018. Epub 2018 Aug 29.

Division of Hematology and Oncology, Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA.

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http://dx.doi.org/10.1136/bcr-2018-225486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6119364PMC
August 2018

To the Editor: 'Non-criteria' antiphospholipid antibodies and thrombosis.

Cleve Clin J Med 2018 06;85(6):431-432

University of Florida College of Medicine, Jacksonville, FL, USA.

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http://dx.doi.org/10.3949/ccjm.85c.06001DOI Listing
June 2018

Pilot study on the occurrence of multiple cancers following cancer-related therapy at the University of Florida, Jacksonville (2011-2016).

J Investig Med 2018 10 6;66(7):1050-1054. Epub 2018 Jun 6.

Hematology and Oncology Department, University of Florida College of Medicine, Jacksonville, Florida, USA.

New primary cancers can occur in patients with a previous cancer. Among the risk factors, therapies such as chemotherapy, radiotherapy, and hormonal therapy have been associated with the development of neoplasms. Second cancers most commonly develop 5-10 years after the initial tumor. We observe the implications of cancer-related therapy in the development of a new tumor. We looked at 602 patients who had their first cancer diagnosed in 2011 and calculated the number of different primary cancers between 2011 and 2016 for each patient. Twenty-four patients had a second cancer within 5 years from the first diagnosis and there were no patients with a third cancer. There was no statically significant difference in the rates of second cancers after exposure to chemotherapy, radiotherapy, hormonal therapy, or any combination of these (p=0.738). Of the second cancers reported after 2011, renal, uterine, cervical, and lung cancers were the most frequently reported. Additionally, there was no statically significant difference among the rates of second cancers in men versus women (p=0.467), as well as among whites versus blacks (p=0.318). We conclude that while new primaries can occur after one cancer, there was no increased risk after exposure to different cancer-related therapies. With increased focus on the primary disease, there is a higher likelihood of missing another primary lesion. This is important as the practical implications of managing multiple primaries are rarely discussed.
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http://dx.doi.org/10.1136/jim-2018-000772DOI Listing
October 2018

DKA-induced Brugada phenocopy mimicking STEMI.

Heart Asia 2018 26;10(2):e011027. Epub 2018 May 26.

Department of Internal Medicine, University of Florida, Jacksonville, Florida, USA.

Case Presentation: A 47-year-old Caucasian woman with type 1 diabetes presented with epigastric pain and vomiting. She had not been adherent with her diet and insulin therapy for the past 3 weeks. She never had a personal or family history of arrhythmia-related symptoms, ventricular tachycardia or fibrillation (VT/VF) or premature sudden cardiac death (SCD). Examination revealed dry mucosa, tachycardia and epigastric tenderness to palpation. Her ECG showed ST elevations (V1-V3) with associated T wave inversions (figure 1A). A baseline ECG 1 year ago had no abnormalities. Serial troponin I and T were negative, but Creatinine Kinase MB (CKMB) was elevated. Her biochemistry test showed sodium of 118 mM, potassium of 6.7 mM, bicarbonate of 4 mM, anion gap of 40, glucose of 985 mM and beta hydroxyl-butyrate of >45.0 mg/dL. Cardiac catheterisation revealed normal anatomy with all vessels widely patent; left ventricular end diastolic pressure (LVEDP) was 1 mm Hg. With treatment, diabetic ketoacidosis (DKA) resolved after 8 hours and repeat ECG showed all changes had resolved (figure 1B). She was monitored on telemetry without any VT/VF episodes. Serial ECGs were done with resolution of changes. She had no positive studies for inducible VT. The rest of her admission was uneventful.Figure 1(A) ECG on presentation. (B) ECG 8 hours after admission.

Question: Which of the following is the best next step in managing this patient?Quinidine therapy.Implantable cardioverter-defibrillator (ICD) placement. gene mutation testing.Observation without therapy.
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http://dx.doi.org/10.1136/heartasia-2018-011027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5976109PMC
May 2018

Syncope in a middle-aged man.

Emerg Med J 2018 Jun;35(6):395-401

Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA.

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http://dx.doi.org/10.1136/emermed-2017-207381DOI Listing
June 2018

Dynamic right ventricular outflow tract obstruction from a pedunculated cardiac metastasis.

J Echocardiogr 2018 12 25;16(4):185-186. Epub 2018 Apr 25.

Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA.

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http://dx.doi.org/10.1007/s12574-018-0379-3DOI Listing
December 2018

Acute glomerulonephritis secondary to .

BMJ Case Rep 2018 Mar 9;2018. Epub 2018 Mar 9.

Hotz Children's Hospital, Jackson Health Sysrem, Miami, Florida, USA.

is a clinically important pathogen that is emerging globally but remains poorly investigated. Here, we report the first case of acute glomerulonephritis resulting from infection with Glomerulonephritis is typically caused by and reports secondary to other strains including and exist. Infection with in this patient was associated with acute nephritis (haematuria, oedema and hypertension), nephrotic syndrome and progressive azotemia. There was activation of the complement system. The presence of low C1q and elevated anti-C1q binding complexes points to a potential pathogenic role. Testing for streptococcal antigens was strongly positive. Emerging nephritogenic strains of present a significant health concern for both developed and developing countries.
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http://dx.doi.org/10.1136/bcr-2017-223314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5847902PMC
March 2018

Paraneoplastic acral vascular syndrome.

Cleve Clin J Med 2018 Feb;85(2):101-102

Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, FL, USA.

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http://dx.doi.org/10.3949/ccjm.85a.17007DOI Listing
February 2018

Coexistent Ipsilateral Internal Carotid Artery Occlusion and Cerebral Venous Thrombosis in Hepatitis C.

J Investig Med High Impact Case Rep 2018 Jan-Mar;6(1):2324709617750179. Epub 2018 Jan 9.

University of Florida, Jacksonville, FL, USA.

A 58-year-old male, known to have hepatitis C virus (HCV), presented with intermittent headaches and left-sided sensorimotor symptoms. There were no focal neurological deficits on examination. Electrocardiogram was unremarkable. Computed tomography angiography head and neck displayed extracranial right internal carotid artery occlusion. Magnetic resonance imaging showed right cortical vein thrombosis, with hemorrhagic infarction. Echocardiography with bubble study was unremarkable. Hypercoagulable workup was significant for protein S deficiency. He was treated with warfarin for 6 months. Repeat protein S levels remained low 9 months later. The coexistence of arterial and venous thrombotic events gives rise to a limited differential. In this case, it may be related to chronic HCV infection. The underlying pathogenesis is not clear; however, it is possible the patient had chronic high-grade internal carotid artery stenosis, which occluded leading to his presenting symptoms. The cortical vein thrombosis is likely an incidental finding here. The extent by which HCV contributed to the cerebral thrombosis and carotid artery occlusion in our case is not clear; however, the hypercoagulable and atherosclerotic properties of the virus cannot be disregarded. The virus can promote carotid atherosclerosis and cerebral venous thrombosis as well as other venous and arterial thromboembolic events. Furthermore, HCV is associated with impaired venous flow and procoagulant properties, which can fuel a hypercoagulable state. Also of note cirrhosis is associated with protein S deficiency. We recommend considering an underlying hypercoagulable state including both arterial and venous thrombosis in HCV infection.
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http://dx.doi.org/10.1177/2324709617750179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5768283PMC
January 2018

Severe beta blocker and calcium channel blocker overdose: Role of high dose insulin.

Am J Emerg Med 2018 Apr 10;36(4):736.e5-736.e6. Epub 2018 Jan 10.

Department of Internal Medicine, University of Florida, College of Medicine, Jacksonville, United States.

A 54-year-old female presented after taking an overdose of an unknown amount of hydrochlorothiazide, doxazocin, atenolol and amlodipine. She was initially refractory to treatment with conventional therapy (intravenous fluids, activated charcoal, glucagon 5 mg followed with glucagon drip, calcium gluconate 10%, and atropine). Furthermore, insulin at 4 U/kg was not effective in improving her hemodynamics. Shortly after high dose insulin was achieved with 10 U/kg, there was dramatic improvement in hemodynamics resulting in three of five vasopressors being weaned off in 8 h. She was subsequently off all vasopressors after six additional hours. The role of high dose insulin has been documented in prior cases, however it is generally recommended after other conventional therapies have failed. However, there are other reports that suggest it as initial therapy. Our patient failed conventional therapies and responded well only with maximum dose of insulin. Physicians should consider high dose insulin early in severe beta blocker or calcium channel blocker overdose for improvement in hemodynamics. This leads to early discontinuation of vasopressors. It is important that emergency physicians be aware of the beneficial effects of high dose insulin when initiated early as opposed to waiting for conventional therapy to fail; as these patients often present first to the emergency department. Early initiation in the emergency department can be beneficial in these patients.
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http://dx.doi.org/10.1016/j.ajem.2018.01.038DOI Listing
April 2018

Enterococcal Empyema and Trapped Lung in Systemic Lupus Erythematosus.

J Glob Infect Dis 2017 Oct-Dec;9(4):162-163

Department of Medicine, Eric Williams Medical Sciences Complex, San Fernando, Trinidad and Tobago.

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http://dx.doi.org/10.4103/jgid.jgid_34_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750442PMC
January 2018

Letrozole-induced hepatitis with autoimmune features: a rare adverse drug reaction with review of the relevant literature.

Oxf Med Case Reports 2017 Nov 13;2017(11):omx074. Epub 2017 Nov 13.

Department of Haematology and Oncology, University of Florida College of Medicine Jacksonville, FL, USA.

While aromatase inhibitors (AIs) have been known to cause minor elevations in liver enzymes, severe hepatotoxicity is rare. To the best of our knowledge, this is the first reported case of Letrozole-induced hepatitis with autoimmune features. A 70-year-old female with estrogen positive, invasive ductal carcinoma of the breast, presented with jaundice 3 months after starting letrozole. Hepatic transaminases were markedly elevated and her ANA and anti-smooth muscle antibody was positive. Liver biopsy featured drug-induced hepatitis. After stopping letrozole, liver tests trended back to normal within 3 weeks. She scored 9 for Roussel-Uclaf Causality Assessment Method (RUCAM). Over the last 10 years, there have been reported cases of drug-induced hepatitis secondary to AIs. We anticipate that there will be more widespread use of AIs based on recommendations from the TEXT, SOFT and extended AI trials. Therefore, physicians must be aware of this rare but life-threatening complication.
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http://dx.doi.org/10.1093/omcr/omx074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5691789PMC
November 2017
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