Clinics and Practice

Dihydropyrimidine dehydrogenase (DPD) is the major enzyme in the catabolism of 5-Fluorouracil (5-FU) and its prodrug capecitabine. We report cases from our institute with colorectal cancer who experienced severe toxicities to standard dose 5-FU based chemotherapy. DPYD gene sequencing revealed rare different polymorphisms that prompted dose adjustments of administered 5-FU and capecitabine. To our knowledge, this is the first case series looking at DPYD polymorphisms in the Saudi Arabian population. Full article

Although rare, acute myelogenous leukemia (AML) can include extramedullary manifestations, sometimes presenting as a solid tumor called a myeloid sarcoma. Myeloid sarcoma can be the cause of the initial presenting complaint before AML diagnosis, or may be detected as a sign of disease-relapse after treatment. Here, we report a case in which the initial presentation included abdominal discomfort and signs of kidney failure. Further investigation revealed signs of unilateral hydronephrosis. Due to a diagnostic delay, the patient was diagnosed with AML with extramedullary manifestation only after the development of full-blown leukemia. Biopsy of the compressive tumor confirmed an extramedullary myeloid sarcoma, and [¹⁸F]-FDG-PET/CT proved useful for patient diagnosis and follow-up. This case report illustrates the importance of thorough examination and diagnosis, as a serious underlying disease with a rare cause can debut with an unusual presentation. Full article

A 41-year-old woman with no significant past medical history presented to the hospital with complaints of nausea, vomiting, and generalized weakness over two weeks. The patient did not seek medical attention as she assumed that her symptoms willwould resolve. Following her initial denial of drug abuse and her abnormal urine drug screening, we discussed the findings with the patient. She later admitted to using both amphetamines and marijuana. This led us to take a detailed social history that revealed an unexpected event. Full article

Small-cell lung cancer (SCLC) is an aggressive subtype of lung cancer characterized by a rapid initial response and early development of resistance to systemic therapy and radiation. The management of SCLC significantly changed for the first time in decades with the introduction of immune checkpoint inhibitors. Pembrolizumab, a humanized IgG4 isotype antibody, targets the programmed cell death protein 1 (PD-1) pathway to restore anti-tumor immunity. Prospective trials of pembrolizumab in patients with previously treated SCLC showed significant durability of responses. These results led to the U.S. Food and Drug Administration (FDA) granting pembrolizumab accelerated approval as second- or third-line monotherapy for patients with extensive-stage (ES) SCLC. In a recent clinical trial that included patients with previously untreated ES-SCLC, pembrolizumab in combination with platinum/etoposide met its progression-free survival endpoint, but overall survival (OS) did not cross the threshold for superiority. With the therapeutic landscape for SCLC rapidly evolving, we review prior experience and future directions of pembrolizumab in ES-SCLC. Full article

Diseases of the breast in adolescent women are usually benign, and their treatment is simple using appropriate medical strategy and rarely surgical therapy. The whole team’s real challenge is when the girl presents malignant breast cancer symptoms such as a non-movable tumor, nipple discharge, nipple retraction, retraction of the skin, inflammatory infiltration of the breast, or ulceration. Presented here is a case of a 15-years-old girl with the features of a malignant neoplasm of the breast. There was an observed non-movable tumor, retraction of the nipple, inflammatory infiltration, and pain. The performed ultrasound and magnetic resonance imaging suggested a malignant lesion measuring 84 mm × 66 mm × 50 mm. After many diagnostic difficulties, the lesion evacuated spontaneously, and the abscess was diagnosed. In conclusion, not all features of a malignant breast tumor in adult women are typical for adolescent females. In young girls, breast diseases are usually benign, and appropriate diagnostics and therapy allow for an effective cure. Atypical breast lesions require the extraordinary cooperation of a multidisciplinary team. Full article

Left ventricular assist device implantation is a challenging procedure in the presence of a giant thrombosed aneurysm, and no standard surgical techniques are currently recommended in this setting. In this case, we report the successful implantation of a left ventricular assist device (HeartMate III) in a patient with a massive thrombosed apical aneurysm. The patient presented with extended antero-apical necrosis as a result of a delay in hospital admission for acute coronary syndrome due to the patient’s concerns about the COVID-19 pandemic outbreak. Full article

Radiotherapy plays an important role in the treatment of localized primary malignancies involving the chest wall or intrathoracic malignancies. Secondary effects of radiotherapy on the lung result in radiation-induced lung disease. The phases of lung injury from radiation range from acute pneumonitis to chronic pulmonary fibrosis. Radiation pneumonitis is a clinical diagnosis based on the history of radiation, imaging findings, and the presence of classic symptoms after exclusion of infection, pulmonary embolism, heart failure, drug-induced pneumonitis, and progression of the primary tumor. Computed tomography (CT) is the preferred imaging modality as it provides a better picture of parenchymal changes. Lung biopsy is rarely required for the diagnosis. Treatment is necessary only for symptomatic patients. Mild symptoms can be treated with inhaled steroids while subacute to moderate symptoms with impaired lung function require oral corticosteroids. Patients who do not tolerate or are refractory to steroids can be considered for treatment with immunosuppressive agents such as azathioprine and cyclosporine. Improvements in radiation technique, as well as early diagnosis and appropriate treatment with high-dose steroids, will lead to lower rates of pneumonitis and an overall good prognosis. Full article

We report a 38-year-old female patient affected with anti-citrullinated protein antibody (ACPA)-positive rheumatoid arthritis (RA) who developed mild hemolytic anemia (Hb = 10.5 vs. >12 gr/dL), indolent oral ulceration, ANA (1:1280, homogeneous pattern), and anti-dsDNA antibody positivity following 8 months of therapy with an adalimumab biosimilar (GP2017). Rhupus syndrome was diagnosed. Replacing GP2017 with infliximab, anemia, oral ulcer, and anti-dsDNA antibodies quickly disappeared, while low-titers (1:80) ANA are still present after more than a year. The possibility that the patient suffered from rhupus rather than drug-induced lupus erythematosus associated to anti-ACPA positivity RA was discussed. To date, after a 14-month follow-up, no manifestations of LE have reappeared. To the best of our knowledge, this is the first report of adalimumab-induced rhupus. Full article

Background and Aims: This study sought (i) to adapt cross-culturally the Brazilian Portuguese-translated version of the MSRA questionnaire, (ii) to estimate the prevalence of risk of sarcopenia, and (iii) to correlate the MSRA Portuguese version with CC in hospitalized cancer patients. Methods: This was a cross-sectional study developed at the hospital in the year 2018. After being translated and adapted to the Portuguese language, the questionnaire was applied and associated with the measurement of calf circumference (CC) to verify its validity. Results: Of the 45 patients, 71.1% presented significant or severe body weight loss, and 55.5% indicated muscle mass loss (CC < 31 cm). From the MSRA of seven and five items, 91.1 and 84.5% of the patients, respectively, presented risk for sarcopenia. Among those at risk for sarcopenia, more than 60% were aged <70 years, >80% were hospitalized in the last year, more than 40% could not walk > 1000 m, >40% did not eat regularly, and >80% lost >2 kg in the last year. CC was correlated with MSRA of five items (r = 0.46, p = 0.001) and seven items (r = 0.53, p = 0.0002). Furthermore, both versions of the MSRA (seven and five items) presented strong agreement and high reliability. Conclusions: The MSRA full and short version was adapted for a Brazilian Portuguese-translated version and showed strong agreement and high reliability to identify the risk for sarcopenia in hospitalized cancer patients. Therefore, this questionnaire can be used as part of nutritional assessment protocols in order to enable early screening of the risk for sarcopenia Full article

Aims: The progression of prediabetes to T2DM can be delayed through diet modification and weight management. However, the intensive lifestyle program is often not covered by medical insurance. This retrospective analysis evaluates the association of a patient self-paid weight management program on an improvement of blood sugar in overweight and obese patients with impaired fasting glucose (IFG). Methods: The medical records of 4634 patients who participated in the self-pay UCLA Weight Management Program were reviewed and 2572 patients met the criteria for this retrospective analysis to examine whether this program was associated with the reversal of IFG over 3 months among 1396 patients with normal fasting glucose (NFG) and 1176 with IFG. Results: The patients with IFG lost comparable amounts of weight (10.5 ± 1.3 kg) at three months, as did the subjects with NFG (10.1 ± 1.3 kg). Fasting blood glucose in the IFG group decreased from 108.49 ± 6.4 to 101.8 ± 9.41 mg/dL (p < 0.0001) after three months. There were also significant reductions in triglycerides, and both systolic and diastolic blood pressure in both groups in association with weight loss. Conclusion: Our medically supervised self-pay multidisciplinary weight management program was associated with reduced fasting blood glucose levels in patients with IFG over three months with comparable weight loss to patients with NFG. Full article

(1) The aim of the present study was to describe the endoscopic and histopathological findings in the esophagus, stomach, and duodenum in patients with Crohn’s disease. (2) Methods: This was a cross-sectional study that included patients receiving treatment from the inflammatory bowel disease outpatient clinic. Esophagogastroduodenoscopies with biopsies of the stomach and proximal duodenum were performed. Presence of Helicobacter pylori bacteria was assessed by Giemsa staining. (3) Results: We included 58 patients. Erosive esophagitis was identified in 25 patients (43.1%), gastritis was diagnosed in 32 patients (55.2%) and erosive duodenitis was found in eight (13.8%). The most frequent histopathological finding in the H. pylori-positive group was increased inflammatory activity in the gastric body and antrum, with a predominance of mononuclear and polymorphonuclear cells. In turn, the most frequent finding in the H. pylori-negative group was chronic inflammation with predominance of mononuclear cells. Focally enhanced gastritis was identified in four patients (6.9%), all of whom were negative for H. pylori. Granulomas were not observed. H. pylori infection was present in 19 patients (32.8%). (4) Conclusions: Nonspecific endoscopic and histological findings were frequent in patients with Crohn’s disease. Focally enhanced gastritis was uncommon and observed only in H. pylori-negative patients. The time from the diagnosis, patient age, and therapy in use may have influenced the nondetection of epithelioid granuloma. Full article

The total number of COVID-19 positive cases in Latvia has escalated rapidly since October 2020, peaking in late December 2020 and early January 2021. Children generally develop COVID-19 more mildly than adults; however, it can be complicated by multisystem inflammatory syndrome in children (MIS-C). This case study aims were to assess demographic characteristics and the underlying medical conditions, and clinical, investigative and treatment data among 13 MIS-C patients using electronic medical records. All 13 had acute illness or contact with someone who was COVID-19 positive two to six weeks before MIS-C onset. Only five of the 13 were symptomatic during the acute COVID-19 phase. The median age was 8.8 years; 11/13 patients were male, 10/13 had been previously healthy, and all 13 patients tested positive for SARS-CoV-2 by RT-PCR or antibody testing. The most commonly involved organ systems were the gastrointestinal (13/13), hematologic (13/13), cardiovascular (13/13), skin and mucosa (13/13), and respiratory (12/13) ones. The median hospital stay was 13 (interquartile range, 11 to 18) days; 7/13 patients received intensive care, 6/13 oxygen support, and 5/13 received inotropic support. No deaths occurred. During the current pandemic, every child with a fever should have a clearly defined epidemiological history of COVID-19, a careful clinical assessment of possible multiple organ-system involvement, with a special focus on children with severe abdominal pain and/or skin and mucocutaneous lesions. Full article

Pancytopenia is a decrease across cellular hematological lines. Many different etiologies can cause this clinical picture including viral and bacterial infections, chemicals, malignancy, and medications. Particular attention should be paid to the onset, timing, and severity as they can indicate the underlying cause. In cases of iatrogenic-induced pancytopenia, the offending agent should be stopped immediately and the patient should be monitored for recovery of cell lines. While not well reported in the literature, trimethoprim–sulfamethoxazole (TMP-SMX) is a cause of pancytopenia. We present a case of drug-induced pancytopenia secondary to TMP-SMX that resolved quickly with cessation of use. Full article

Patients with chronic wounds (leg ulcers, decubitus, and diabetic foot ulcers) suffer from marked restrictions in their quality of life and can often no longer adequately carry out their everyday tasks. The need for nursing and medical care increases when other illnesses and complaints are present at the same time. Qualified wound care and the treatment of comorbidities are therefore of particular importance. The treatment of this disease, which is increasing in number, requires a holistic, multimodal treatment approach which, in addition to professional wound care, also includes comorbidities in the treatment. This case study describes an old treatment method for refractory wounds, the so-called “maggot therapy”, and shows how this is integrated into a holistic, multimodal therapeutic approach. Full article

(1) Objective: To review the criteria proposed by Cerero-Lapiedra et al. and to retrospectively identify the under-diagnosed disease in patients diagnosed with proliferative verrucous leukoplakia. (2) Materials and methods: In this study, we included patients who were diagnosed with leukoplakia (histological label consistent with the clinical diagnosis, n = 95), and cases with a final diagnosis within the spectrum of proliferative verrucous leukoplakia (n = 110) as defined by Batsakis et al. We applied the criteria proposed by Cerero-Lepiedra et al. to screen for the possible cases of proliferative verrucous leukoplakia. (3) Results: Although many of our patients satisfied specific isolated criteria, only 11 cases satisfied specific combinations of the guidelines to satisfy a diagnosis of proliferative verrucous leukoplakia. However, due to the lack of follow-up data, the disease is not confirmed in these 11 cases. (4) Conclusion: A limited number of cases of proliferative verrucous leukoplakia were diagnosed using the criteria given by Cerero-Lapiedra et al. The true natural history of the disease could not be studied due to the lack of follow-up data. (5) Clinical relevance: Proliferative verrucous leukoplakia presenting as hyperkeratosis or mild epithelial dysplasia are often not followed up, and they subsequently transform into carcinoma. Thus, clinicians must be vigilant whenever they encounter leukoplakia, especially with multifocal presentations. In such cases, the follow-up data are the key to understanding the true nature of the disease entity. Full article

This is a retrospective case series of two patients with laboratory-confirmed coronavirus 2 (SARS-CoV-2) infection, presented to the University of Arkansas for Medical Sciences in January 2021. Medical records of these patients were reviewed using the EPIC electronic health record system. Clinical, laboratory, and treatment data were reviewed against periods of bradycardia in each patient. Both of the patients presented with dizziness and presyncope related to sinus bradycardia in which they received treatment with 1 mg of IV atropine and theophylline 200 mg orally. We share these two cases of theophylline treatment in COVID-19 induced sinus bradycardia. The first patient was a 39-year-old female, with a past medical history of polycystic ovarian syndrome, who presented to the emergency department with lightheadedness and dizziness. Two weeks prior to her presentation, she was tested positive for COVID-19 infection that was treated with azithromycin, dexamethasone and aspirin. Upon presentation, her ECG showed sinus bradycardia at a rate of 48 bpm. The second patient, a 21-year-old female with no significant past medical history, presented with presyncope. Three weeks prior to her presentation, she tested positive for COVID-19 infection that was treated symptomatically at her home. Upon presentation, her ECG showed junctional rhythm at a heart rate of 51 bpm. Full article

A 68-year-old female patient with a past medical history of atrial fibrillation on anticoagulation regimen with Apixaban and Clopidogrel presented for her scheduled Watchman device implantation. The device was indicated as patient was high risk for falling. Successful implantation of the left atrial appendage device was carried out, and the patient was sent to the floor. One hour after the procedure, the patient started having left-sided diplopia along with severe eye pain. An immediate CT scan of the head showed left superior orbital mass, concerning for hematoma. Urgent left canthotomy with cantholysis was conducted bedside. However, despite early interventions, the patient’s vision was lost. Full article

Upper cross syndrome (UCS) is a condition caused from prolonged poor posture manifesting as thoracic hyperkyphosis with forward head and shoulder postures. It has been associated with several other secondary conditions, causing pain and discomfort to those with the condition. This is a case report of a 35-year-old female presenting to clinic with a sharp pain in the neck, upper back, and sternum area for 4 weeks and gastroesophageal reflux disease (GERD). She had been working at home for several months after the shelter at home order was issued. Following evaluation and corrective treatment with cervical adjustment and soft tissue massage, the patient’s posture improved and reported full pain resolution. Her symptoms of GERD concurrently resolved as well. She continued to receive chiropractic adjustment two times per month for correcting spinal misalignment. Full restoration of posture was attained on the full spine radiographs at 9 months follow-up. The patient remained symptom-free at 12 months follow-up. Manipulative and preventive therapies aimed at treating and preventing UCS should be more widely adopted to prevent secondary conditions. Full article

As the world continues to suffer from an ever-growing number of confirmed cases of the SARS-CoV-2 novel coronavirus, researchers are at the forefront of developing the best plan to overcome this pandemic through analyzing the pathogenesis, prevention, and treatment options pertaining to the virus. In the midst of a pandemic, the main route for detection of the virus has been conducting antigen tests for rapid results, using qRT-PCR, and conducting more accurate molecular tests, using rRT-PCR, on samples from patients. Most common treatments for those infected with COVID-19 include Remdesivir, an antiviral, dexamethasone, a steroid, and rarely, monoclonal antibody treatments. Although these treatments exist and are used commonly in hospitals all around the globe, clinicians often challenge the efficacy and benefit of these remedies for the patient. Furthermore, targeted therapies largely focus on interfering with or reducing the binding of viral receptors and host cell receptors affected by the SARS-CoV-2 novel coronavirus. In addition to treatment, the most efficacious method of preventing the spread of COVID-19 is the development of multiple vaccines that have been distributed as well as the development of multiple vaccine candidates that are proving hopeful in preventing severe symptoms of the virus. The exaggerated immune response to the virus proves to be a worrying complication due to widespread inflammation and subsequent clinical sequela. The medical and scientific community as a whole will be expected to respond with the latest in technology and research, and further studies into the pathogenesis, clinical implications, identification, diagnosis, and treatment of COVID-19 will push society past this pandemic. Full article