A 49-year-old man developed lung and liver metastasis a few months after surgery and adjuvant radiotherapy for salivary duct carcinoma of the parotid gland. There was no response to palliative chemotherapy with doxorubicin. We followed the biological model of breast cancer, whereby two-thirds of human epidermal growth factor receptor 2 positive patients respond to a combination of docetaxel and human epidermal growth factor receptor 2 blocker (trastuzumab). A durable, complete response was achieved with this combination. A rationalised treatment approach targeting the biological characteristics of salivary duct carcinoma had proven successful.
Anticonvulsant hypersensitivity syndrome (AHS) is a rare but potentially life-threatening reaction that occurs in response to common anticonvulsants in predisposed individuals. It is often characterized by fever, rash, lymphadenopathy, hepatitis, and laboratory abnormalities. Consequently, it often is overlooked or even misdiagnosed by practitioners unfamiliar with AHS. Cross-sensitivity manifests frequently between phenytoin, phenobarbital, and carbamazepine as an exacerbation of presenting signs and symptoms. We report a case of AHS in a patient whose clinical features changed significantly when switching from phenytoin to carbamazepine. Physicians and pharmacists must become aware of the extreme variability in AHS manifestation so that the offending anticonvulsant regimen can be discontinued in a timely manner.
nephrotoxic medications, Charlson Index > 5, daily vancomycin dose > 4 grams, baseline renal dysfunction, IV contrast, and vasopressor therapy. Results: Mean vancomycin trough was 17.28 mg/L (range of 4.8 to 59 mg/L), with 60 (35.5%) patients admitted to the ICU during vancomycin therapy. A large proportion of vancomycin troughs were not therapeutic; 76 (46%) patients had subtherapeutic troughs and 54 (32%) patients had supratherapeutic troughs. Age > 65 years (OR 1.98, CI 0.264 -0.926, p = 0.033) was the only statistically significant risk factor for subtherapeutic troughs, and BMI > 35 (OR 2.454, CI 1.035-5.819, p = 0.042) was the only statistically significant risk factor for supratherapeutic vancomycin troughs. Vasopressors (OR 0.040, CI 1.042 -6.010, p=0.04) and concomitant nephrotoxic agents (OR 1.043 -6.845, p=0.41) were associated with nephrotoxicity. Conclusions: This was the first study that assessed the use of a high dose vancomycin nomogram in a wide variety of hospitalized patients. Utilization of a high dose vancomycin nomogram resulted in a large proportion of patients with subtherapeutic or supratherapeutic vancomycin serum concentrations. Deviation from the HDVN and frequent monitoring should be strongly considered in patients who are older than 65 years of age, morbidly obese, receiving nephrotoxic medications, or on vasopressor therapy.
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