Catastrophic Antiphospholipid Syndrome Presenting as Diffuse Peripheral and Central Thromboses

Case report - Introduction: Catastrophic Antiphospholipid Syndrome (cAPS) is the most severe form of antiphospholipid syndrome with a high mortality;it is characterised by multiorgan involvement that develops within a short time frame and usually consists of microvascular thrombosis. We present the case of a 50-year-old lady with recurrent microvascular and macrovascular thromboses who was initially treated with endovascular stents and amputation progressing to require immunosuppression and anticoagulation, to include steroids, rituximab, intravenous immunoglobulin and plasma exchange. Case report - Case description: A 50-year-old lady presented to the Emergency Department with bilateral leg and abdominal pain. Her comorbidities included type two diabetes, psoriasis, three miscarriages, borderline personality disorder and a heavy smoking history. Clinical examination revealed pulse deficits in the distal lower limbs with gangrene evidence of ischaemia on her toe digits. CT angiogram demonstrated complete thrombus of the Infrarenal abdominal aorta extending to the common iliac and external iliac arteries bilaterally. Thrombolysis ensued and an aortic stent was inserted with symptom relief. Two weeks later readmission occurred with bilateral leg pain;Ultrasound Doppler revealed a tight stenosis at the distal aortic region. Initial management consisted of Intravenous heparin but worsening ischaemia resulted in insertion of kissing stents at the aortic bifurcation. The patient's pain settled with no residual arterial compromise. One month later the patient was re-admitted with bilateral leg pain and necrotic right toes;this led to a right forefoot amputation. A triphasic bilateral finger colour change was noted with ischaemic pain and livedo reticularis on lower limbs, with a decision to institute Iloprost and methylprednisolone ensued. Antiphospholipid antibodies returned showing triple positivity. Management subsequently included addition of IV rituximab, plasma exchange, IVIG and sildenafil. Two months later the patient was re-admitted with complete lower limb paralysis due to a complete thrombus of the aortic bi-iliac stent;thrombolysis ensued with good result. A further admission 1- month later occurred due to sepsis and an infected necrotic left forefoot resulting in an above knee amputation. No further endovascular stenting was advised to risk of embolic seeding following medical management. Case report - Discussion: We have described a case of cAPS on a previously asymptomatic female patient who presented with diffuse peripheral and central thromboses. Our patient suffered from intraabdominal organ infarction and subsequent acute kidney injury, recurrent arterial and venous occlusion over a period of 12 months and previous pulmonary emboli. Livedo reticularis and gangrene were visible cutaneous manifestations of this disorder on our patient. cAPS accounts for less than 1% of APS and has a high mortality of 50% which means early and frequent discussion with specialist centres is important. In addition to the clinical features described in our patient, laboratory features included moderate thrombocytopaenia and evidence of haemolysis (raised bilirubin and LDH). The cAPS registry demonstrates that the majority of patients are female (72%) with a mean age of 37 years, 46% have primary APS, 40% suffer from SLE and 9% from other autoimmune diseases. This patient does not have a secondary autoimmune condition. The most common clinical features to present before cAPS develops include foetal loss, previous DVT or thrombocytopaenia, two of which our patient demonstrated. The prognosis and clinical features of cAPS have been shown to depend on the extent of thrombosis, organs affected and the presence of a systemic immune response from affected tissues. Treatment options available for cAPS consist of multiorgan support, anticoagulation and immunosuppression, in the form of glucocorticoids, rituximab, IV Immunoglobulin and plasma exchange. Our patient required all of these due to accelerating thrombosis as determined b new gangrene, ongoing livedo reticularis rash and thrombocytopenia. Case report - Key learning points: Our case demonstrates the importance of keeping a high index of suspicion for cAPS as up to 46% will have this as their first presenting feature of APS - including our patient. On her admission to hospital particular attention was paid to clinical examination which suggested Raynauds and a skin rash consistent with livedo reticularis - this prompted a rheumatology consult, serology testing, starting Iloprost and tertiary centre transfer. The diagnosis was secure with high titre of IgG anticardiolipin antibody, anti Beta-2 glycoprotein 1 antibodies and Lupus Anticoagulant detected- all on two occasions more than 12 weeks apart. Patients may present to surgical specialties in view of peripheral vascular symptoms and signs. It would be appropriate to identify patients with APS early to prevent multiple surgeries or considerations for endovascular stents, as they are frequently not successful. This case highlights the need for discussion and education within the multidisciplinary setting for patients with APS, including surgical teams. Finally, the risk of immunosuppression for patients who have received rituximab can persist for up to 12 months following treatment and this lady also had the co-morbidity of diabetes. This patient's risk stratification was high in view of COVID-19 and she was advised to shield until government guidelines ended last year. Currently she is doing well without new symptoms and she will be reviewed at 6 months following rituximab, in the Autumn of 2021.

Ingestion of Alcohol-Based Hand Sanitizer: A case report

Introduction: Alcohol-based hand sanitizers containing ethanol or is opropanol are being used in order to prevent person-to-person transmission during the COVID-19. Early signs and symptoms of this ingestion include nausea, vomiting, headache, abdominal pain, blurred vision, loss of coordination, and decreased level of consciousness. After hand sanitizer ingestion we have to suspect about methanol poisoning, monitoring the start of anion-gap metabolic acidosis, seizures, and blindness is essential. Treatment includes supportive care, acidosis correction, and the administration of an alcohol dehydrogenase inhibitor. In servere cases hemodialysis may be required. Objective(s): To present a case of an 29-year-old woman who was taken to the emergency department after voluntary ingestion of alcohol-based hand sanitizer in a suicide attempt. To describe the most common side effects of hand sanitizer ingestion and the literature review. Method(s): Clinical case presentation and literature review of similar cases. Result(s): A 29-year-old woman, with diagnosis of borderline personality disorder and previous suicide attempts was taken to the emergency department after 3 hours of voluntary ingestion of an unknown quantity of alcohol-based hand sanitizer. Initial laboratory findings showed laboratory a blood methanol concentration of 66 mg/dL, with an anion gap of 30 mEq/L, arterial blood pH of 7.2, serum bicarbonate concentration of 12 mEq/L. Patient complained of abdominal pain and nervoussness. Conclusion(s): Most common signs and symptoms of alcohol-based hand sanitizer ingestion include nausea, vomiting, headache, abdominal pain, blurred vision, loss of coordination, and decreased level of consciousness. Treatment includes supportive care, acidosis correction, the administration of an alcohol dehydrogenase inhibitor and sometimes may be required.

Patients' Satisfaction with the quality of online versus in-person DBT skills group therapy: A pilot study

Introduction: Since the beginning of the COVID-19 era, there has been a major shift of psychiatry and psychotherapy practice to the online venues, or what has been broadly known as telepsychiatry. A practice that has been very practical since then. And yet, there has been a debate about the patients' degree of satisfaction with the therapeutic process, especially with a modality like group therapy, which has not been widely researched. Objective(s): The objective of this pilot is to assess the level of patients' satisfaction among both online and in-person participants of dialectical behavioral therapy (DBT) skills group as a part of comprehensive outpatient DBT program. Method(s): 27 DBT skills group participants completed an online form including demographic data, type and duration of group attended, in addition to the Arabic version of the Satisfaction with Therapy and Therapist Scale- Revised (STTS-R). Result(s): The majority of the 27 participants were females (88.9%), of which 81.4% were 18-34 years old and 77.4 % at least had a university degree. Among all the participants, 63% were online group attendants versus 37% in-person. The mean total of patient's satisfaction with the in-person group was 53.5 in comparison to 49.2 in online group participants. Also, 90% of in-person group participants reported that the group helped them in dealing with presenting problem to an extent in comparison to 82.2% of online participants. Conclusion(s): Although the COVID-19 pandemic mandated more use of telepsychiatry, in-person DBT skills group participants reported higher satisfaction of their therapy in comparison to online group participants.

Neuropsychiatric implications of covid-19 infection: A case report

Introduction: During the COVID19 pandemic numerous cases of neuropsychiatric complications were reported as a result of COVID19. Objective(s): Presentation of a clinical case and literature review of new cases of neuropsychiatric complications after SARS-CoV2. Method(s): We present the case of a 43-year-old woman in follow-up for 15 years borderline personality disorder who was diagnosed with SARS-CoV2 pneumonia without signs of severity. Throughout the admission the patient, who had no history of epilepsy or other neurological affections, presented up to 5 generalized tonicclonic seizures during 15 days. Result(s): In the ECG was evidenced intercritical epileptiform activity predominantly right frontotemporal. No analytical alterations were observed, neither in the imaging tests (cranial MRI and CT). Lumbar puncture was normal. During the admission, he presents an affective deterioration, with generalized impoverishment, decreased functional autonomy and hearing voices without structured delusional ideation. No previous psychotic history. Her previous treatment with Sertraline 100mg was suspended and valproic acid was added (1300 mg/day) which, being insufficient in the control of seizures, was necessary to boost with Levetiracetam (1000 mg/12h). Risperidone 3 mg and Diazepam 5 mg/8h were added to control psychotic symptoms. In the subsequent follow-up, previous antipsychotic treatment was gradually discontinued. The patient evolved favorably without new psychotic symptoms and clinical stability was observed with euthymia. Conclusion(s): Taking care of these complications it is necessary to avoid misdiagnosing. It is essential to expand the study of this entities in the context of COVID19 in order to increase knowledge and to be able to carry out an adequate approach and follow-up.

A Case of Autosarcophagy in a Pediatric Patient With Depression

BACKGROUND: Self-mutilating behavior in the pediatric population is associated with psychiatric and psychosocial factors. Autosarcophagy, or self-cannibalism, is an extremely rare form of self-mutilation and is predominantly seen with psychosis or substance use.1 We report a case of oral autosarcophagy in a pediatric patient in the absence of substance use or psychosis. OBJECTIVE: To learn about autosarcophagy and its treatment in the pediatric population and to explore other neuropsychiatric disorders in which it is a predominant manifestation. METHODS: Review of a case using electronic medical records and relevant literature. Key terms: 'autosarcophagy,' 'body focused repetitive behavior,' 'oral self injury,' 'pediatric self-mutilation' using Medscape and Google Scholar. RESULTS: We present a 14-year-old female with history of seizure disorder in full remission, depression, self-cutting behavior, and suicidal ideation with 2 psychiatric hospitalizations, who presented to the pediatric emergency department with oral bleeding after eating one-third of her tongue over the course of a month. Evaluation was notable for poverty of speech and constricted affect. Patient stated she was 'trying to remove an infection' and alleviate discomfort. She denied that this behavior was an attempt to end her life but endorsed past suicidal ideations and cutting behavior. History revealed emergency room evaluation for aggressive behavior and episodes of volitional enuresis. We diagnosed major depressive disorder, recurrent episode in remission without psychosis. Drug screen, complete blood count, complete metabolic panel, COVID-19, urinalysis, thyroid-stimulating hormone, head computed tomography, and beta-human chorionic gonadotropin were negative. Patient continued home oral medications aripiprazole 10 mg daily, fluoxetine 30 mg daily, and levetiracetam 500 mg twice daily and was discharged the next day. CONCLUSIONS: Self-harm is observed in 17.2% of adolescents, 13.4% of young adults, and 5.5% of older adults.2 Cases of self-mutilation in pediatric patients typically present as cutting, burning, or head banging.3 Our differential diagnoses include borderline personality disorder due to repeated impulsivity and self-harm, and body focused repetitive behavior disorder (obsessive-compulsive disorder-related disorder), which presents with repetitive strain injuries and dental malocclusions. Treatment of self-mutilation involves treating the underlying psychiatric condition with psychotropic medications.4,5 In pediatric patients, dialectical behavioral therapy has been shown to reduce parasuicidal behaviors after 1 year of therapy.6 Our patient, under constant 24-hour observation, was cleared by medical, psychiatric, and dental teams. The patient followed up with outpatient psychotherapy and psychiatry. We are presenting this rare case for clinicians to identify and manage pediatric patients presenting with unique forms of self-harm tendencies.