We report a case report of hyperleukocytosis, fever, hypotension, pulmonary and pericardial effusions, and acute kidney injury during initial treatment with azacitidine in a patient with AML-MRC. Collectively, the symptomatology resembled differentiation syndrome. Azacitidine has been previously associated with fever, peripheral edema, and hyperleukocytosis, but its side effect profile has never been described as similar to differentiation syndrome. The patient's deteriorating course quickly turned around after treatment with dexamethasone. This potential reaction, and potential treatment, is important for clinicians to be aware of.
Tick paralysis is caused by a neurotoxin secreted in the saliva of a gravid female tick, and manifests with ataxia, areflexia, ascending paralysis, bulbar palsy, and ophthalmoparesis. An 84-year-old man presented in June in coastal Mississippi with several days of subacute ataxia, bulbar palsy, unilateral weakness, and absent deep tendon reflexes. MRI/MRA and extensive serum and cerebrospinal fluid investigations were unrevealing. His symptoms progressed over several days, until his nurse discovered and removed an engorged tick from his gluteal fold. Within hours of tick removal, his subacute symptoms completely resolved. While tick paralysis is rare in adults, it is a condition that internists should be familiar with, particularly in seasons and areas with high prevalence of disease. This case also highlights the importance of performing a thorough skin exam on patients with the aforementioned neurologic abnormalities. INTRODUCTIONTick paralysis is a rare condition caused by the secretion of a neurotoxin in the saliva of a gravid female tick. 1,2It manifests with ascending paralysis, ataxia, areflexia, bulbar symptoms (dysphagia, dysphonia, dysarthria), and ophthalmoparesis (weakness of the extraocular muscles) after several days of tick attachment.1 Peak incidence is in the summertime, when the tick emerges from hibernation.1 In contrast to pediatric populations, which are typically affected, adults are rarely affected, as the neurotoxin concentration is thought to be attenuated by the larger adult body mass.3 Without tick removal, the disease can quickly become life-threatening, compromising respiratory muscle strength and resulting in respiratory failure. If missed, tick paralysis can portend significant morbidity and mortality.2 The hallmark feature of tick paralysis is a dramatic resolution of symptoms with one of the easiest treatments available-tick removal. 4 CASE PRESENTATIONAn 84-year-old man presented in June in coastal Mississippi with two days of unsteady gait and slurred speech. He was oriented to person, place, time, and situation, and did not have any memory loss. He had a past medical history of hypothyroidism, chronic kidney disease stage 3, and hyperlipidemia, but no prior history of stroke or alcoholism. At baseline, he reported having a normal gait and performance status. There were no antecedent illnesses, vaccinations, travel, new medications, known insect bites, or alcohol binges. Social history revealed that he was an avid outdoorsman in a rural community and that he consumed 1-2 drinks per week but had no history of heavy alcohol use. On exam, the patient was a wellgroomed man whose vital signs were within normal limits and whose body mass index was 25. On neurologic exam, he was alert and oriented to person, place, time, and situation. His speech was slurred, but with normal comprehension. Cranial nerve exam revealed bilateral ophthalmoparesis, evidenced by weakness in his extraocular movements. Motor exam revealed bilateral upper extremity pronator drift, with the left arm more prom...
Reed syndrome is a heritable cancer predisposition syndrome that can easily be missed due to its simple presentation of tender red papules. We present a young female with a history of uterine fibroids who presented to the dermatology clinic with several painful pink papules that had been previously evaluated by multiple physicians. Biopsy results were diagnostic for cutaneous leiomyomas, raising clinical suspicion for Reed syndrome. She was found to have a novel heterozygote mutation in her fumarate hydratase gene, supporting the diagnosis. This case demonstrates the importance of rendering a proper workup for seemingly innocent skin complaints as they could be associated with an underlying malignancy. Despite the fact that up to 16% of patients can develop aggressive type 2 papillary renal cell carcinoma, there are currently no consensus guidelines on screening or patient management.
BackgroundIn 2012, the Centers for Disease Control (CDC) recommended hepatitis C virus (HCV) screening for those born between 1945 and 1965. Prior recommendations endorsed screening based on risk factors (RFs). Because United States (US) military retirees have had at least 20 years of access to free comprehensive health care, mandatory physical fitness tests, periodic health assessments and mandatory drug screening, we hypothesized that the prevalence of HCV amongst military retirees is lower than the national average. Thus the new CDC screening guidelines may not be applicable or cost effective in this particular population.MethodsA quality improvement (QI) initiative implemented the new birth-cohort CDC screening guidelines for the internal medicine (IM) clinic of our hospital (QI group). An age-matched group from the same IM clinic, screened based on RFs for HCV infection, served as the comparator (RF group). The prevalence of the anti-HCV antibody and chronic infection was determined and compared with each other and with the national average.ResultsThe prevalence of the HCV antibody was 2.1% and 2.3% in the QI and RF groups, respectively (odds ratio (OR): 1.08, 95% CI: 0.37 - 3.21, P = 1.000). The prevalence of chronic infection was 0.4% and 1.8% in the QI and RF groups, respectively (OR: 4.39, 95% CI: 0.80 - 24.13, P = 0.083). When our data were compared with the national average, there were no statistical differences in the prevalence of the HCV antibody; however, there was statistically more viral clearance, and subsequently less chronic infection, in the QI group versus the national average.ConclusionsThe military retiree population did not have a lower prevalence of the HCV antibody than the American populace whether screened based on age or traditional RFs. Thus, the CDC guidelines are applicable in this population. One interesting finding of this study is the higher rate of viral clearance in military retirees when compared with the national average. It is therefore possible that military retirees may be more likely to have natural viral eradication than the civilian population.
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