Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

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Delayed Paclitaxel-Induced Interstitial Pneumonitis With Impressive Resolution Palmer, C, D.O. Merolli, A, M.D. Kent Hospital, Internal Medicine Residency Program, Warwick RI. Introduction: Drug Induced Lung Disease (DILD) often due to medications, herbals, or illicit drugs. Common offenders include NSAIDS, ACE Inhibitors, Methotrexate, and Amiodarone. Patterns of DILD include diffuse alveolar hemorrhage, hypersensitivity pneumonitis, interstitial lung disease, etc. The chemotherapy agent, Paclitaxel, is a rare cause of DILD. It's a serious condition that can lead to acute respiratory failure requiring mechanical ventilation. We have a case of a 48 year old female with history of recurrent stage IIIA ovarian cancer receiving paclitaxel chemotherapy presenting with hypoxia. Case: A 48-year-old female with a history of recurrent stage IIIA ovarian cancer was admitted to the hospital with worsening abdominal pain and plan for laparotomy. She had completed her last of three cycles of Paclitaxel over three weeks prior to presentation. Unfortunately, on exploratory laparotomy she was found to have extensive abdominal metastatic disease, so the plan was medical management only. Postoperatively she was hospitalized for decreased urine output and abdominal pain requiring a patient-controlled analgesic pump. On postoperative day three, her oxygen saturation was found to be low at rest and 70% with ambulation. At this time she admitted to a two to three week history of dyspnea on exertion, but denied any sensation of acute shortness of breath. At that time she was febrile at 38.4C and tachycardic at 112bpm. Her exam was significant for bilateral lower extremity edema and right sided expiratory wheezing. A chest radiograph was performed revealing bilateral diffuse infiltrates without effusions. Her labs revealed a normal leukocyte count, normal B- Natriuretic Peptide, and negative blood cultures. The surgical team diuresed the patient based on radiology report. Twenty four hours later, she had a second hypoxic episode while on oxygen. At this time, pulmonary embolism was ruled out with a chest CT scan, but results revealed impressive symmetric bilateral ground glass opacities sparing the peripheral lung fields. The radiology report communicated concern for pulmonary edema versus bilateral pneumonia. At this point medical consultation was obtained. Although there is a broad differential for ground glass opacifications, the diagnosis was most consistent with interstitial/hypersensitivity pneumonitis with evidence of alveolar filling defects. Intravenous steroids were initiated and within 48-72 hours the patient's clinical picture markedly improved. Due to the patient reported chronicity and the CT findings we had come to the conclusion that this was unlikely infectious and more likely a Paclitaxel-induced hypersensitivity interstitial pneumonitis. Repeat chest CT one month later revealed complete resolution of the pneumonitis. Discussion: DILD secondary to Paclitaxel dosed every three weeks as in this case occurs in less than 1% of patients. Case reports have indicated the importance of recognizing and treating this condition early. Although most cases have documented pulmonary toxicity within minutes to hours after Paclitaxel infusion, the rarer delayed hypersensitivity effects can manifest weeks following treatment. Keeping this in mind, physicians must recognize that DILD can occur long after Paclitaxel administration and intravenous steroids need to be administered immediately. This case also emphasizes the importance of reading one’s own radiological images and generating a differential diagnosis regardless of the official report.
Severe Autoimmune Hemolytic Anemia with Renal Neoplasm Parikh, S, D.O., Rhodes, E, D.O., Dicomo, J, MSIII, Bhattacharrya, N, M.D. St. Joseph’s Regional Medical Center, Dept. of Surgery, Paterson, NJ Introduction: Hemolytic anemia is a process by which the destruction of red blood cells (RBCs) causes an abnormally low level of hemoglobin. Autoimmune hemolytic anemia (AHA) is a type of hemolytic anemia characterized by autoantibodies directed against red blood cells shortening their survival. When autoimmune hemolytic anemia is secondary to a paraneoplastic process, severe anemia can occur leading to significant morbidity and even mortality. Here we discuss the literature and present the case of a child with autoimmune hemolytic anemia from a paraneoplastic syndrome secondary to renal cell cancer. Case: A four year old male presented to the emergency department with three days of vomiting, fever, and upper respiratory symptoms. He had scleral icterus, jaundice, delayed capillary refill and soft, and a non-distended abdomen. Laboratory evaluation revealed a white blood cell count of 62,500 (bands of 9%), hemoglobin of 2.6 g/dL, hematocrit of 6.8% and platelets of 569,000. A bone marrow biopsy performed on admission yielded results consistent with hemolytic anemia; furthermore, testing revealed that this anemia was consistent with an autoimmune type based on cold agglutinins. Abdominal MRI demonstrated a large right midpole kidney lesion. The patient underwent intraoperative biopsy of the right renal mass. After pathologic analysis of frozen specimen, it was likely that this was a malignancy and a right radical nephrectomy with en bloc resection of surrounding tissue was performed. The final pathology was renal neoplasm with predominately cystic growth pattern and possible blastoma components suggestive of a well differentiated Wilm’s tumor. Discussion: AHA is well documented in lymphomas and ovarian dermoid cyst, but rarely reported in solid tumors. A recent study subdivided solid tumor AHA into occurrence before, concurrently, and after cancer treatment. Results of the study showed that AHA after resection can be followed for both remission and recurrence. Although extremely rare as an entity, we believe that AHA can be used as a marker for recurrence/remission. We also believe that because AHA can occur after tumor resection, it is underreported and misdiagnosed.
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Page 7 and 8: Atypical Presentation for Complex R
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