Objective: To determine the frequency of autoimmune cytopenias in chronic lymphocytic leukemia. Methods: This cross sectional study was carried out at Department of Hematology, Army Medical College Rawalpindi, in collaboration with Military Hospital Rawalpindi and Armed Forces institute of Pathology Rawalpindi from 1st January 2018 to 1st October 2018. Sample size of 64 was calculated using WHO calculator. Age and gender of patients was noted. Frequency of autoimmune hemolytic anaemia, immune thrombocytopenic purpura, pure red cell aplasia and autoimmune agranulocytosis were determined in diagnosed patients of chronic lymphocytic leukemia by various laboratory tests in our study population. Results: A total of 64 patients were included in the study, 53 (82.8%) were males and 11(17.2%) were females. Mean age of patients was 65 years. Autoimmune hemolytic anaemia was observed in 5/64 (7.8%) of patients. Immune thrombocytopenic purpura was seen in 2/64 (3.1%) patients. Autoimmune granuloytopenia and pure red cell aplasia were not seen in any patient. Conclusion: Autoimmune hemolytic anaemia and immune thrombocytopenic purpura are the most common causes of immune cytopenias in patients of CLL. Immune cytopenias should always be identified by laboratory tests as their management differs from other cytopenias which occur due to various other causes. doi: https://doi.org/10.12669/pjms.35.5.369 How to cite this:Haider MS, Khan SA, Nasiruddin, Shahid S. Autoimmune cytopenias in chronic lymphocytic leukemia. Pak J Med Sci. 2019;35(5):---------. doi: https://doi.org/10.12669/pjms.35.5.369 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cryptococcosis is an invasive yeast infection commonly found among immunosuppressed patients. Pulmonary cryptococcal infection can have variable presentations ranging from pulmonary nodules and masses to consolidation. A patient can present with shortness of breath, cough, sputum production, chest pain, fatigue, and weight loss. Diagnosis can be made using fungal culture, histology, radiographic findings, and cryptococcal antigen in serum as well as in the cerebrospinal fluid. Treatment is usually with a combination or a single antifungal agent. Few cases have been reported in immunocompetent individuals.Here we present a case of 69-year-old immunocompetent individual, who was initially seen in the outpatient clinic for dyspnea, cough, and fatigue and was treated for pneumonia. The patient remained symptomatic despite multiple courses of oral antibiotics. He was then sent for inpatient admission. CT scan was obtained that showed patchy infiltrates and consolidations, followed by bronchoscopy. The cytology confirmed adenocarcinoma. The fungal smear and culture grew Cryptococcus neoformans. The patient was treated with fluconazole with improvement of his symptoms before starting chemotherapy.We are reporting this case as clinicians usually focus on bacterial etiologies in outpatient setting. Our patient, who was immunocompetent, had a new diagnosis of cryptococcal pneumonia and was also found to have lung adenocarcinoma. This case highlights the rare occurrence of this type of pneumonia in immunocompetent patients and the importance of considering fungal causes of pneumonia in patients.

The condition autoimmune progesterone dermatitis (APD) is an immune disorder, observed among women, primarily due to progesterone surge during menstrual cycle. Here, we present a case of a 29-year-old female with recurrent severe skin eruptions associated with her menstrual cycle that commenced a few years ago. She presented with blistered skin lesion of the body and also blisters in oropharyngeal mucosa leading to a variety of symptoms ranging from pruritus to difficulty in swallowing. Recognition of this process is important as it can result in significant debility among women. Our patient was treated with steroids and antihistamines to provide symptomatic relief and was encouraged to resume her oral contraceptive pill, which is a more definitive therapy.

Superior vena cava (SVC) syndrome is a clinical entity with signs and symptoms resulting from obstruction of blood flow through the SVC. The resulting obstruction leads to edema in the upper body, including the head, neck, and upper extremities. Clinical signs and symptoms can include plethora, cyanosis, dyspnea, stridor, cough, and hoarseness, as well as more serious complications such as cerebral edema leading to headache, confusion, and coma. Here, we present an interesting case of a 66-year-old female, with a medical history of esophageal cancer in remission and thyroid cancer currently undergoing radiation therapy, who was admitted for facial and upper extremity swelling. The initial impression was of angioedema or an allergic reaction. Imaging studies showed thrombus in the SVC resulting in SVC syndrome. The patient was treated with heparin initially, with a plan for an interventional radiologist to perform catheter-guided thrombolysis. However, the patient became unstable and ended up requiring mechanical ventilation. The patient was eventually discharged on oral anticoagulants. This case was rare as the patient developed SVC syndrome from venous thrombosis in the absence of any external tumor compression or as a result of an intravascular catheter.

Subcutaneous implantable cardioverter-defibrillators (S-ICD) provide an effective treatment option for ventricular arrhythmias. When compared to transvenous implantable cardioverter-defibrillators (TV-ICDs), S-ICDs have a lower infection rate but a higher rate of inappropriate shocks. In patients with end-stage renal disease (ESRD), significant electrolyte disturbances are commonly seen, such as hyperkalemia, which can cause an increase in T wave amplitude. We present a patient with ESRD on hemodialysis who experienced inappropriate shocks from an S-ICD during sinus rhythm due to hyperkalemia-induced T wave oversensing and highlight related cases in the current literature.

IntroductionHepatitis B virus (HBV) is the leading cause of cirrhosis in the developing world. Despite the development of effective vaccine(s) and direct-acting antivirals (DAAs) such as tenofovir and entecavir, the eradication of chronic HBV remains a distant dream in endemic regions. Factors such as treatment naivety, longer duration of disease, late diagnosis, family history of liver disorders and hepatocellular carcinoma, fatty liver disease, multiple comorbidities, alcoholism, use of tobacco products, noncompliance to drugs, and loss to follow-up all contribute to disease progression and development of complications.In order to promote a better understanding of the treatment initiation, duration, and eventual outcomes, the European Association for the Study of the Liver (EASL) updated its guidelines in 2017 and introduced a new staging system for chronic HBV. Since these guidelines are relatively recent, data regarding the new staging is virtually absent in local/regional settings. Moreover, it has been observed that patients presenting to secondary care setups at major urban centers have disease characteristics quite distinct from those of their rural counterparts or patients presenting to tertiary care setups, even in the same cities. Additionally, there is scarce published data with regard to this aspect. With this study, we hope to make progress on all of those fronts.