First introduced in 1963, ommaya reservoirs (OmRs) are indwelling intraventricular catheters used for decompression of hydrocephalus, antibiotics, and chemotherapy delivery. They are important alternatives when lumbar punctures are not practical or when long-term administration of medications is needed. Despite being used for over 50 years, placement of these devices can still contribute to significant morbidity and mortality. We performed a single-center retrospective review at the University of Florida Cancer Center evaluating OmR related complications in patients in whom OmR was placed for chemotherapy. We also conducted a systematic review of OmR related and LP complications in setting of chemotherapy delivery. 13 patients met criteria for inclusion in this retrospective study. Time points evaluated for complications were: placement, up to 6 months, 6-12 months, > 12 months, removal and post-discharge. Our institutional data showed a complicated rate of <7% at each time point. For systematic review, 38 studies were reviewed for OmR data, and 8 studies were reviewed for LP data. Infectious complications were more prevalent in OmR studies with statistical significance (p=0.0017), whereas noninfectious complications were more prevalent in LP studies with statistical significance (p=0.0004). This study compared complication rates from infectious and non-infectious sources between patients receiving intrathecal chemotherapy through Ommaya reservoirs versus lumbar puncture. OmR can be very useful in long-term administration of medication, and the relatively high complication rate (especially infectious) can be deemed an acceptable risk for patient population with high morbidity.
A 33-year-old male with poorly controlled chronic tophaceous gout and chronic kidney disease (CKD) with estimated glomerular filtration rate (GFR) of 37 cc/min. His uric acid was 11 mg/dL despite maximal dosing of febuxostat. He had previously failed pegloticase infusions as well. This patient had a reduction in his uric acid level to less than 6 mg/dL following addition of probenecid to his febuxostat regimen. Most guidelines recommend against utilisation of probenecid therapy in patients with GFR <50, but there is no obvious contraindication to its use, provided renal calculi do not develop. Our case illustrates the synergistic effect probenecid can add to maximal xanthine oxidase inhibitor therapy for patients with refractory hyperuricaemia in a patient with CKD stage IIIb. With the approval of a new uricosuric medication, lesinurad, probenecid may remain a suitable alternative for patients with financial limitations to achieve target uric acid levels.
A 48-year-old woman with recurrent syncope presented with acute left vision loss after another syncopal fall. She reported no prodromal symptoms and no prior syncope workup. Vital signs were normal. Ophthalmologic exam revealed left corneal ulcerations. Cardiopulmonary and neurologic examinations were unremarkable. Brain MRI, carotid ultrasound, serial troponins, telemetry, and EKG were normal. Transthoracic echocardiography uncovered a diagnosis of cor triatriatum, an obstructing patent membrane in a dilated, bisected left atrium ( Fig. 1) with constricted blood flow and increased flow velocity across the restrictive orifice (Fig. 2).Cor triatriatum represents only 0.1-0.4% of congenital cardiac malformations and has several anatomic variants. 1,2 Ventricular inflow obstruction results from abnormal septation within the left or right atrium, creating two atrial chambers subdivided by a thin membrane. Many remain asymptomatic until their thirties. Most cases in adulthood are discovered incidentally. [3][4][5] Clinicians should suspect cor triatriatum in young healthy patients with clinical features mimicking mitral stenosis but no cardiovascular co-morbidities. Early and severe manifestations occur in smaller communicating orifices and higher obstruction between bisected atrial chambers. 1 Late symptoms results from progressive increase in pulmonary artery pressure. 2 Syncope, heart failure, and sudden cardiac arrest are well cited. 5,6 Early diagnosis by echocardiography is important to expedite surgical cure. 2,7,8
Multiple endocrine neoplasia type 2B (MEN2B) is the rarest and most aggressive of the MEN syndromes. It is characterised by medullary thyroid cancer (MTC), pheochromocytoma, marfanoid body habitus, mucosal neuromas and colonic dysfunction. Patients typically present with chronic constipation and MTC in early childhood. We discuss an atypical late presentation of MEN2B in a 19-year-old man with chronic constipation since childhood admitted with acute spinal cord compression. He underwent emergent neurosurgical intervention followed by postoperative radiotherapy. Bone biopsy revealed metastatic pheochromocytoma. Thyroid nodule biopsy showed MTC. MIBG scan confirmed pheochromocytoma as the dominant malignancy. Germline testing revealed a RET mutation (p.M918T). He received one cycle of cyclophosphamide, vincristine and dacarbazine and subsequently developed a pathological right femur fracture requiring repair. Postoperative course was complicated by hypoxic respiratory failure requiring intubation. Imaging showed lymphangitic spread of disease in the lungs. He unfortunately did not respond to a short trial of sunitinib and transitioned to comfort care.
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