Journal of Clinical Case Reports

A 22-year-old female with no previous morbidities presented with acute onset neurological symptoms in the form of hemi sensory phenomenon. On evaluation she had fever and routine COVID-19 RT-PCR testing turned out to be positive. During the course of hospital stay she developed classical features of acquired TTP. Her ADAMTS 13 level was 36% of normal activity suggestive of direct viral mediated thrombotic microangiopathy. High vWF levels and low ADAMTS 13 activity is reported in COVID-19 Infection. In rare cases like ours this can mimic classical TTP.

The plausible causative role of nabumetone in severe Stevens-Johnson syndrome in a 27-year old healthy female was shown by the Lymphocyte Stimulation Test (LST). In 2 healthy controls, LST was negative, and nabumetone did not prevent lymphocyte stimulation by phytohemagglutinin. The positive LST is somewhat surprising, because the patient had not been exposed by the drug previously and already the first 2 tablets induced the reaction.

The results suggest that LST can be useful in the diagnostics of severe life-threatening drug reaction, but the use of multiple drug dilutions is necessary in the case of suspected antigen that possesses anti-inflammatory properties. It can be possible that the positive LST and clinical reaction are related to crossreactivity between anti-inflammatory analgesic drugs. Also it may be possible that even a short transient time of nabumetone in blood before biotransformation may trigger a severe drug reaction.

Chronic non-scarring scalp folliculitis is common in younger age group, more so in men. The common causative agents are gram-positive organisms like Pityrosporum acnes and Staphylococcus aureus.

Gram-negative scalp folliculitis caused by Klebsiella is an uncommon entity. Skin and soft tissue infection by Klebsiella alone is rare. It could be caused by bacterial interference and replacement of the Gram-positive flora of the skin, where long-term antibacterial treatments are given. The uncommon occurrence of gram-negative folliculitis can lead to common diagnostic dilemma, and, it severely impairs the quality of life of the patient and worsens disease progression.

In this case, a 22 years man had recurrent scalp folliculitis for 2 years, for which multiple courses of antibiotics were taken. Hence, dermatologists require to be vigilant with high index of suspicion in the recalcitrant cases.

Skin eruption from sulfasalazine (salazosulfapyridine, Salazopyrin-^®) was indicated by lymphocyte stimulation test using various concentrations of the metabolites, sulfapyridine and 5-aminosalisylic acid. Only sulfapyridine produced a clear positive stimulation index. Later after about one year, the oral challenge resulted in negative results. The explanation of the developed tolerance for sulfasalazine remains unknown.

The results show that Lymphocyte Stimulation Test (LST) can be useful but may necessitate the use of a series of multiple dilutions in case of studying suspected allergens that possess antilymphocytic proliferative properties.

Tigecycline has a broad antibacterial spectrum and is widely used for severely infected patient. Hypofibrinogenemia is a rare adverse reaction of tigecycline and scarcely reported. We present a case of 58-year-old woman who developed hypofibrinogenemia after tigecycline treatment, without other coagulation parameters changing. Moreover, hypofibrinogenemia reappeared when tigecycline was readministered, and fibrinogen concentration restored to normal level after withdrawing tigecycline. We found that hypofibrinogenemia was probably induced by tigecycline through assessing the causality by Naranjo adverse drug reaction probability scale. Therefore, our case raises concern about an adverse reaction of tigecycline-induced hypofibrinogenemia, especially for critically ill patients with high risk of coagulopathy. In conclusion, we suggest that fibrinogen should be monitored for patients with coagulopathy risk during tigecycline treatment, especially for critically ill patients.