Journal of Clinical Case Reports

A 51-year old women suffering from depression with psychotic symptoms and a history of meningitis and epilepsia since childhood was treated paroxetine, olanzapine and lamotrigine for years.

Introduction: Vitamin D receptor (VDR) plays a key role in the metabolism and differentiation of keratinocytes; thus, associations between VDR polymorphisms with Psoriasis vulgaris (PsV) onset have been sought for many years. The results of these studies have not been conclusive. To date there are no studies in Mexico regarding the association between these polymorphisms and the clinical manifestations of PsV. Objective: The aim of this study was to determine the association between polymorphisms in the VDR gene (FokI, BsmI, ApaI and TaqI) and the clinical manifestations of PsV in a group of Mexican patients. Methods: The study group consisted of 52 patients from north (NPsV n=24) and western (OPsV n=28) regions of the country diagnosed with PsV. This group of patients were compared with healthy donors from the western (POc n=50) and northern (PN n=50) regions. RFLPs were identified to determine allelic and genotypic frequencies for all the groups. Hardy-Weinberg equilibrium (HWE) as well as haplotype distributions were estimated. Statistical tests were X2 and Fisher’s exact test. Haplotype distribution was carried out with SNPstats software. Results: There was no significant difference when the genotypic frequencies between patients and controls are compared; however, there is an association between the TT(ff) genotype of FokI polymorphism and clinical manifestations. The most frequently observed haplotypes of polymorphisms (FokI, BsmI, ApaI and TaqI) have significantly different distributions (p>0.0001) between patients with PsV and controls. Conclusions: Our results show that the polymorphisms FokI, ApaI, BsmI and TaqI in the VDR gene are not associated with the risk of presenting PsV in Mexican population, but the TT(ff) genotype of the FokI polymorphism is significantly more common in patients with late onset of PsV (after age 40) and those without nail affection. More studies including a greater number of samples and other polymorphisms must be analyzed.

Objective: We report a case of pulmonary cement embolism following percutaneous vertebroplasty performed for osteoporotic vertebral compression fracture. Summary of background data: Asymptomatic pulmonary cement embolism, more than symptomatic pulmonary cement embolism, are not so rare from 2.1% to 26%. Methods: The fifth day after surgery, an angioscan was performed because of respiratory failure. It showed a pulmonary cement emboly in the apical segment, medium lobe and ventro-basal segment of the right lung. Results: Symptomatic treatment with oxygen and curative anticoagulation allowed a complete respiratory function recovering. Conclusions: So as to better diagnose this complication, a careful analysis of the post-operativ pulmonary X-ray and regular follow-up are necessary. The main interest of this case report is the knowledge of chest X-ray as a screening test for pulmonary cement embolism.

Background: The tyrosine kinase inhibitor, a new treatment option in hepatic carcinoma, may associate thyroid dysfunction like spontaneously remitting thyrotoxicosis followed by hypothyroidism. Case report: A 66-year Caucasian female was first diagnosed and operated for a moderately differentiated rectal adenocarcinoma of 5 centimeters. Immunohistochemistry showed positive VEGF receptor 2 (Flk-1, KDR), VEGF receptor 1(Flt-1), and a Ki67 of 30%. 4 years later a hepatic adenocarcinoma (clear cells variant) was diagnosed. After surgery, daily 400 mg of sorafenib was introduced. Three months later mild symptomatic thyrotoxicosis was seen: palpitations, fatigue, and mild bilateral pedal clonus. Thyroid-stimulating hormone (TSH) was suppressed (0.044 μIU/mL, normal levels between 0.4 and 4.5 μIU/mL), and free levothyroxine (fT4) elevated. The TSH receptor antibody, the antithyreoglobulin and antithyreoperoxidase antibodies were negative. Thyroid ultrasound pointed hypoechogenic, inhomogeneous aspects. She received beta-blocker and within two months thyrotoxicosis remitted but TSH progressively increased suggesting hypothyroidism with level less 5 μIU/mL so no replacement levothyroxine therapy was added yet. Discussions: The exact mechanism of the tyrosine kinase inhibitors-related thyroid malfunction is not fully understood. Non-autoimmune destructive thyroiditis of unknown trigger causes thyrotoxicosis and later hypothyroidism as seen in our case. The clinical features vary from one person to another. The hormone replacement is rarely necessary. The baseline cancer seems irrelevant for thyroid toxicity. In our unusual case the patient had a history of two metachronous cancers. The thyroid follow up is essential during each patient therapy yet a specific pattern of follow-up is not precisely designed. Conclusion: The tyrosine kinase inhibitor-induced thyroid dysfunction includes both thyrotoxicosis and hypothyroidism. We emphasize the idea of periodic endocrine evaluation in oncologic patient treated with this class of drugs.

Transformation of follicular lymphoma (FL) to Diffuse Large B-Cell Lymphoma (DLBCL) occurs commonly is and associated with a rapidly progressive clinical course that is refractory to treatment and a short survival. The clinical presentation of this transformed disease is variable. We here report a 65 years old man with an atypical presentation of transformed FL. He initially presented with symptoms and clinical signs consistent with Multiple myeloma. His bone marrow biopsy result revealed plasma cell infiltration (CD 138+, CD56-) throughout the marrow. He had a rapid progressive worsening of his condition; he developed liver and renal failure. His imaging studies revealed diffuse lymphadenopathy, an excisional lymph node biopsy done showed FL which had transformed into DLBCL with prominent plasma cell differentiation. He was treated with of R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone) with overall good response but has currently relapsed.

Keratosis Follicularis Spinulosa Decalvans (KFSD) is an X-linked
genodermatosis characterized by scarring alopecia and follicular
hyperkeratosis. This condition mainly affects males with females being
carriers and will have milder symptoms. We present a family of two
siblings of KFSD, boy had nine years and girl had five years old. This
genodermatosis often starts at infancy or early childhood. Keratosis
pilaris atrophicans (KPA) is the umbrella term for a group of three rare
and distinct clinical entities representing the scarring types of keratosis
pilaris.

Plasma cell leukemia is a variant form of multiple myeloma with its own unique form of presentation. It may have
a presentation resembling a lymphoproliferative disorder which if not investigated in detail can lead to misdiagnosis
and thus completely different line of investigation. Our patient presented to us with disturbed dietary regimen,
significant weight loss and was a known case of hypothyroidism since 2009 for which he was on medications. At
the other centre, complete blood picture showed bicytopenia with hyperleucocytosis while bone marrow biopsy
performed showed a diagnosis of lymphoproliferative disorder with a morphological diagnosis of Hairy cell leukemia.
At our center, his complete blood count showed bicytopenia with leucocytosis as before but the morphological
examination of his peripheral smear showed the presence of 80% plasma cells. The immunophenotyping showed
CD23(+) and CD56(+) while the immunohistochemistry showed CD23(+), CD56(+) and CD138(+). Cytogenetics
showed the presence of t(4;14) in 5% of the cells examined. Based on the above mentioned investigations, a
diagnosis of Plasma cell leukemia was reached and the patient was placed on a treatment regimen including
Lenalidomide, Bortezumib and Dexamenthasone. His blood counts came within the normal range within a week
of starting the treatment. Bone marrow biopsy accounts for one of the many steps that should be taken to reach a
correct diagnosis. Keeping in mind the variable presentation a disease can show, as many investigative tools should
be undertaken as is clinically and economically possible for reaching at a correct diagnosis and thus the decision of
the eventual treatment plan for the patient.

Cutaneous metastasis of internal malignancies is not common. Its occurrence is a sign of advanced disease, carrying a very poor prognosis. The survival in most reported cases is a few months. We present a case of cutaneous metastasis of bronchogenic carcinoma that survived almost 3 years after the initial appearance of the cutaneous lesions.

Hydrocodone is an opioid derived from codeine, which has been used for many years as a short-acting analgesic
combined with acetaminophen (or less commonly ibuprofen). Common and severe psychiatric side effects included
include mental depression, mood changes, hallucination, delirium, somnolence, agitation, and dysphoria. This is
a report of a particular case that resulted in acute psychosis after immediately starting on Hydrocodone because
of back pain in a 35 year old male, with no past psychiatrist history. The patient returned to his baseline mental
status after the hydrocodone was discontinued. Earlier research was published about these symptoms are the
ones where hydrocodone was used in combination with other drugs, but in this unique case the patient was not any
other medication except the hydrocodone. This unique case showed an association between the short term use of
hydrocodone and development of psychiatric symptoms. Recognition of these uncommon psychiatric side effects of
hydrocodone usage will allow for early recognition of their etiology, symptoms and treatment. Psychotic symptoms
induce by analgesics are not a common condition but they still remain under diagnosed and untreated.

The uterine cervix is a rare implantation site for ectopic pregnancy, surgical management should be carefully considered due to the risk of severe hemorrhage associated with this treatment. Methotrexate (MTX) is well documented as an effective medical approach in early gestations and low human chorionic gonadotropin (ß-hCG) levels yielding good results. This is the case,of a 39 year old woman with a 6.5 week old cervical pregnancy. Diagnosis was suspected and later confirmed due to the presence of a late, vaginal hemorrhage and pelvic pain, blood quantitative ß-hCG quantification, clinical exploration and ultrasonographic evaluation. Since the patient was hemodinamically stable and had concerns with her fertility we opted for a medical treatment with MTX in a multiple dose regimen. Treatment was successful after 3 doses (62.5 mg. each, IV infusion), applied on days 1, 3 and 5, using leucovorin (1 g) on alternate days as rescue therapy. Initial ß-hCG levels were reported at 211 mIU/mL, by the time the patient was discharged she had a 77.5% decrease on the ß-hCG levels and diminished symptomatology, after two months follow-up, ß-hCG levels were 0 mIU/mL. Medical management successfully eliminated cervical pregnancy, thus avoiding the risks any invasive procedures may pose.

Spontaneous Coronary Artery Dissection (SCAD) is a rare life-threatening cause of acute coronary syndrome. It can affect young patients without atherosclerotic risk factors, particularly women in the antepartum or early post-partum period, as well as geriatric patients at high risk for atherosclerotic disease. The pathogenesis linking SCAD with pregnancy has not been fully elucidated. The few reported cases of SCAD in the setting of concomitant Pulmonary Embolism (PE) may highlight a potential mechanism in the pregnant or postpartum woman. Heretofore, cases of SCAD with the setting of pulmonary embolism have all been treated conservatively with medical therapy. We herein report a case of SCAD in the left anterior descending artery resulting in Non-ST elevation myocardial infarction and low ejection fraction associated with an acute pulmonary embolism in a young post-partum patient who was treated successfully with thrombectomy followed by stent placement. Her cardiac function returned to normal within six months with no recurrence of symptoms. To our knowledge, this is the first case of SC.

There have been only eight cases of non-Hodgkin’s lymphoma with placental involvement published in the literature. Our case is the first case of NK/T-Cell lymphoma involving the placenta. NK and T-cells share a common ontogeny and both express T lineage antigens such as CD2 and CD7, but NK-cells lack surface CD3 and express cytoplasmic CD3 as well as CD16, CD56 and CD57. NK/T-cell lymphoma cells are infected with EBV and positive in-situ hybridization is considered a diagnostic requisite. High plasma EBV DNA is correlated negatively with survival and serial EBV plasma DNA monitoring is useful for assessing therapeutic response and detecting recurrence. There does not appear to be a clear relationship between placental involvement with systemic non-Hodgkin’s lymphoma, nor a direct relationship of transplacental transmission if placental tissue is infiltrated with malignant cells.

A 90 year-old patient with a clinical diagnosis of COPD presented to an urban Canadian emergency department with a complaint of progressive dyspnea for two years despite multiple courses of bronchodilator, antibiotic, and prednisone therapy. Prior chest imaging had not been performed.