Journal of Clinical Case Reports

Purpose: Amiodarone is a medication often utilized in the critical care setting for acute arrhythmic episodes and may be inappropriately continued post-discharge, leading to an increased risk of adverse drug events. The gap in transition of care upon discharge and subsequent failure to discontinue medications initiated during hospitalization can lead to increased healthcare utilization and costs. The presented case serves as an example of the consequences that can result from failure to discontinue amiodarone after hospitalization and demonstrates the role of clinical pharmacists in identifying inappropriately continued therapy to reduce the risk of adverse events.

Case: A 66-year-old female presented to her primary care physician complaining of worsening bilateral hand tremors. Unable to determine the origin of this symptom, the physician asked a clinical pharmacist to perform a comprehensive review of the patient’s medications. The clinical pharmacist discovered that the patient was hospitalized a year prior for sepsis with infective endocarditis. During that hospital stay, she was started on amiodarone for an acute episode of atrial fibrillation. The pharmacist determined that the tremors were likely an adverse drug reaction from amiodarone and also recognized amiodarone as a potentially inappropriate medication for this particular patient. The amiodarone was subsequently discontinued. Within several weeks of discontinuation, the patient’s tremors improved significantly.

Conclusion: This case demonstrates the importance of medication review after initiation of amiodarone during hospitalization. Due to the high potential for toxicity, the use of amiodarone should be reviewed and re-evaluated routinely. Clinical pharmacists can contribute their expert pharmacological knowledge to evaluate the appropriateness of amiodarone during and after transition of care to prevent future adverse outcomes.

Bradycardia is commonly encountered in emergency department. Hyperkalemia may sometime cause bradycardia with block and also synergize with AV node blockers to cause bradycardia and hypoperfusion. We report a 53 years old male with history of hypertension, congestive heart failure and coronary artery disease was admitted to hospital for sudden onset of breathlessness. He underwent Percutaneous Coronary Intervention (PCI) to Left Anterior Descending (LAD) artery and Left Circumflex (LCx) artery one year ago and taking Aspilet 80 mg for daily, Clopidogrel 75 mg daily, Ramipril 5 mg daily, Atorvastatin 20 mg daily, Metoprolol 25 mg daily, Spironolactone 25 mg daily and Frusemide 40 mg daily. Significant physical examination was remarkable for a temperature 97.5’F, blood pressure of 110/70 mmHg, heart rate of 40 beats per minute, oxygen saturation was 99% on air and both lung were full with audible crepitation by auscultation. He was given atropine 0.6 mg bolus and transcutanaeous pacing with unimproved heart rate and then a transvenous pacing was immediately placed before the blood investigation results were returned. His relevant laboratory values were significant for a potassium of 7.99 mmol/L(ref range: 3.5-5.2 mmo/l), creatinine of 458 micmol/L (ref range: 59-104 micmol/L), Urea of 33.9 mmol/L (ref range: 2.7-8.0 mmol/l), random blood glucose of 233mg/dl, sodium 126.8 mmol/L (ref range 135-145 mmol/L), anion gap of 13.5 mmol/? (ref range: 3.6-11.0 mmo/L) and bicarbonate of 15.6 mmil/L (ref range: 22-29 mmol/L). He was given calcium glucoronate, insulin with dextrose, kaexylate, nebulizer salbutamol with significant improvement in his potassium levels to 4.6 in 24 hours. In Cardiac intensive care unit his heart rate was improved and the transvenous pacemaker was turned off the next day.

Dilated Cardiomyopathy (DMC) characterized by Left Ventricular (LV) dilation and systolic dysfunction in the absence of coronary artery disease is a common cause of a Heart Failure (HF) in young adults. Being the final response of myocardium to different genetic and environmental factors, DCM is the most frequent indication for heart transplantation in young population. Assessment of LV dimensions and ejection fraction is indispensable in diagnosis, treatment and risk stratification. Although echocardiography is the most frequently used imaging technique in cardiology, Magnetic Resonance Imaging (MRI) remains the gold standard for LV visualization ensuring precise quantification of cardiac chambers’ diameters and volumes. The case presents acute heart failure decompensation in patient with DCM confirming that MRI could be used not only in deferential diagnosis and therapy strategies appointment but also as an excellent method of assessing treatment outcomes. In this patient baseline and control MRI showed significant LV volumes and systolic function improvement after 3 months of adequate pharmacotherapy, as well as change in cardiomyopathy phenotype pattern.

Introduction: Ramucirumab has become the standard of care in second-line systemic therapy for advanced Hepatocellular Carcinoma (HCC) (AFP ≥400 ng/ml). A Complete Response (CR) to systemic therapy is generally very rare. We encountered a patient who achieved CR to secondline therapy with ramucirumab.

Case presentation: We herein report a case of a 62-year-old male diagnosed with HCC and lung metastases 6 months after liver surgery. AFP and PIVKA-II were elevated and his liver function was Child-Pugh A. Sorafenib at 800 mg as the first-line therapy was administered for 6 weeks, and after the progression of the first-line therapy ramucirumab was administered as second-line systemic therapy. The tumor decreased in size and this was judged to be a partial response. Due to the absence of recurrence for approximately 5 years after the cessation of treatment, the present case was considered to have achieved CR.

Conclusion: We encountered a case of HCC with CR to second-line systemic therapy with ramucirumab after sorafenib. The high affinity of ramucirumab to vascular endothelial growth factor receptor 2 (VEGFR2) may have exerted additional anti-tumor effects in cases refractory to systemic therapy having anti-VEGF effects.

A 48-year-old male was hospitalized at Jackson Memorial Hospital in Miami, Florida for 2 months, after sustaining severe polytrauma following MVA. Due to current hospital practice that is supported by public and private partnerships, the patient was routinely screened for HIV on presentation to the ED, and found to be HIV positive with a CD4 count of 18.84 and an active toxoplasmosis infection. Due to the early detection, the patient was able to receive the imperative treatment he needed and his infection was not able to be hidden by the substantial traumas. This case report highlights the degree of HIV comorbidity within our community and demonstrates that current interventions such as routine screening and linkage to care lead to better outcomes.

Introduction: The angiosome concept was first described in 1987, defining an angiosome as an area of tissue comprising skin, subcutaneous tissue, fascia, muscle and bone supplied by a specific artery and drained by a specific vein. We report a case of a patient who was successfully complex revascularized by open surgery and endovascular techniques based on angiosome concept.

Case presentation: A 73-years-old male patient with critical limb ischemia and type 2 diabetes, presented increasing resting pain in the lower right limb during the last 3 months, followed by necrosis of distal phalanx of I and II toes, wet interdigital necrosis of toes I-II on the right leg, with absence of distal pulses on both limbs. Direct flow into affected angiosome was successfully achieved with right proximal femoral-popliteal saphenous vein bypass and ATA balloon dilatation angioplasty.

Conclusion: The vascular patient with critical ischemia associated to diabetes currently requires a complex treatment including open surgery, endovascular technique and negative pressure therapy to save the lower limbs. The angiosome concept is useful during both open and endovascular tibial revascularisation.

Introduction: The angiosome concept was first described in 1987, defining an angiosome as an area of tissue comprising skin, subcutaneous tissue, fascia, muscle and bone supplied by a specific artery and drained by a specific vein. We report a case of a patient who was successfully complex revascularized by open surgery and endovascular techniques based on angiosome concept.

Case presentation: A 73-years-old male patient with critical limb ischemia and type 2 diabetes, presented increasing resting pain in the lower right limb during the last 3 months, followed by necrosis of distal phalanx of I and II toes, wet interdigital necrosis of toes I-II on the right leg, with absence of distal pulses on both limbs. Direct flow into affected angiosome was successfully achieved with right proximal femoral-popliteal saphenous vein bypass and ATA balloon dilatation angioplasty.

Conclusion: The vascular patient with critical ischemia associated to diabetes currently requires a complex treatment including open surgery, endovascular technique and negative pressure therapy to save the lower limbs. The angiosome concept is useful during both open and endovascular tibial revascularisation.