Deranged Haemostasis: Rifampin-Induced Coagulopathy.

Prothrombin time (PT), first used in 1935, is the most commonly employed marker of coagulopathy to assess bleeding tendency. It is a screening test and measures the time in seconds to the formation of a clot after platelet-poor plasma has been mixed with a thromboplastin reagent consisting of tissue factor, lipids and calcium chloride ions. The International Normalized Ratio (INR) is a standardized number based on the PT of the patient. It is used by clinicians to measure the effectiveness of anticoagulants and to guide therapy. Drugs such as warfarin can affect the level of or the metabolism of vitamin K in the body, which can impact PT and INR levels. A supratherapeutic INR is rare in a patient not on therapy with vitamin K inhibitors and with preserved liver function. Here we describe an elderly man with a supratherapeutic INR, secondary to the use of rifampin. Antibiotic-induced coagulopathy is an extremely rare complication. To the authors' knowledge, this is a unique case of rifampin-induced coagulopathy with no other associated complications of disseminated intravascular coagulation. A literature review revealed a small number of cases of rifampicin-induced coagulopathy. A high index of suspicion and knowledge is essential for the diagnosis and management of such cases. LEARNING POINTS: Given the unpredictability and rarity of rifampicin-induced coagulopathy in clinical practice, clinicians should be aware of the possibility of bleeding or drug-induced thromboembolic events with antibiotics.Early recognition and withdrawal of the offending agent are key to the successful management of this condition.Clinicians should be aware of the possible side effects of administered drugs and their possible interactions.

Henoch-Schonlein Purpura in a Newly Diagnosed HIV Patient.

HIV infection is associated with multisystemic manifestations due both to secondary infections caused by a decrease in the CD4+ T-cell count and to the pathogenicity of the HIV virus itself. A common renal manifestation is HIV-associated nephropathy, which is frequently seen in the African population with the APOL1 gene mutation; however, other forms of glomerulopathy such as IgA nephropathy, commonly noted in other ethnicities, are also seen. Vasculitis has rarely been associated with HIV infection and mainly involves small blood vessels, although any size of blood vessel may be involved. The association of Henoch-Schonlein purpura (HSP) with HIV is rare and not well understood. We describe a 53-year-old African American woman with a newly diagnosed HIV infection who presented with a purpuric rash over the bilateral lower extremities with haematuria. Initial work-up revealed renal dysfunction with elevated ESR. Urinalysis was positive for glomerular haematuria and sub-nephrotic range proteinuria. Serum complement level, c-antineutrophil cytoplasmic antibody (ANCA), p-ANCA and anti-nuclear antibody (ANA) were negative. Renal biopsy revealed mesangial IgA deposits with crescent glomerulopathy and fibrinoid necrosis, while skin biopsy revealed leucocytoclastic vasculitis. A diagnosis of HSP was made based on American College of Rheumatology (ACR) criteria. The patient's renal function and purpura improved with a 5-day course of steroid pulse therapy. This case of HSP in a newly diagnosed HIV patient is unusual for the presence of crescentic glomerulopathy. LEARNING POINTS: Henoch-Schonlein purpura (HSP) associated with HIV infection is uncommon but documented; however, all four features of HSP are rarely seen together.Crescent glomerulopathy is rarely seen in HIV-associated HSP.HSP associated with HIV is treated with antiretroviral drugs, while the role of steroid and immunosuppressive therapy remains controversial.

When Blood Is Being Difficult: Clotting and Bleeding in a Patient With Antiphospholipid Antibody Syndrome and Supratherapeutic International Normalized Ratio.

Venous thromboembolism includes deep venous thrombosis (DVT) and pulmonary embolism and is the most common cardiovascular disease after coronary artery disease and stroke. Antiphospholipid syndrome (APS) is an autoimmune disorder that is characterized by venous or arterial thrombosis with laboratory evidence of antiphospholipid antibodies. Long-term anticoagulation therapy is required to prevent recurrent DVTs, embolisms, and thrombosis-related complications. Treatment options include vitamin K antagonists, subcutaneous low-molecular-weight heparin, unfractionated heparin, or direct oral anticoagulants. Warfarin (a vitamin K antagonist) remains the mainstay of treatment in APS patients with a prior history of DVT and is associated with elevation of the international normalized ratio which is often used as a marker for therapy appropriateness and warfarin dosing. Here, we describe a unique case of a 65-year-old female with APS on warfarin (given prior lower extremity DVT) presenting with bleeding/hematoma in the left breast and a clot in the left upper extremity.

A Middle Aged Gentleman Presenting with Subacute Neurosyphilis: Report and Literature Review.

Syphilis is a sexually transmitted disease spread by spirochete Treponema Pallidum, it has a varied range of symptoms and is divided into stages primary, secondary and tertiary. Central nervous system (CNS) invasion occurs early in the disease in almost all the patients, and does not follow any particular stage. However, clinical manifestation depends on whether inflammatory response occurs. (1)(2) Early neurosyphilis typically affects cerebrospinal fluid (CSF) and meninges presenting like meningitis, while late affects the brain and spinal cord parenchyma, presenting as tabes dorsalis and paresis. Here we present a case of a patient with symptomatic neurosyphilis presenting with CSF findings of bacterial meningitis.

Blood Being Tricky: Anticoagulation-Resistant Venous Thromboembolism (VTE).

Venous thromboembolism (VTE) is a condition in which blood clots form in the venous system of the body. It includes deep venous thrombosis (DVT) that occurs when a blood clot forms in a deep vein, more common in lower extremities, and pulmonary embolism (PE) as the clot breaks loose and travels through the bloodstream to the pulmonary arteries. VTE can result in significant morbidity and mortality. It is a preventable medical condition with the treatment being straightforward in most cases with anticoagulation and mechanical thrombectomy. Here, we discuss a rare case of a 40-year-old male with recurrent VTE that was resistant to different available therapeutic options such as direct oral anticoagulants (DOAC), vitamin k antagonists, heparin, and catheter-directed thrombolysis presenting with occlusive thrombus in the entirety of the right-sided deep venous structures, with minimal preservation of flow in the common femoral vein.

A Signet Cell Carcinoma of the Ileum: A Rare Differential Diagnosis of Intestinal Pathology with Fistula Mimicking Crohn's Disease.

Colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of cancer-related death in the USA. Primary signet ring cell carcinoma (SRCC) of the colon and rectum is extremely rare with a reported incidence of less than 1%. Here we present the case of a 41-year-old man who presented with abdominal pain, severe microcytic anaemia and a negative faecal occult blood test (FOBT). A CT scan of the abdomen revealed thickening of the terminal ileum and proximal right colon with extensive lymphadenopathy and a fistula tract extending from the terminal ileum to the right buttock. Endoscopic features like cobblestoning of the ileocolic junction along with elevated blood and stool inflammatory markers raised suspicion of Crohn's disease (CD). However, histopathological study surprisingly revealed primary colorectal signet cell carcinoma (PCRSCC) with no evidence of CD. Cases of simultaneous PCRSCC and CD have been reported, but no clear association has been established. Our case is unique in that it presented with classic clinical features of CD, but PCRSCC without any histological evidence of underlying CD was found on histology. LEARNING POINTS: A rare case of primary colorectal signet cell carcinoma of the colon is described.Primary signet cell carcinoma of the colon can present with severe microcytic anaemia and abdominal pain.Signet cell carcinoma can mimic Crohn's disease on radiological and endoscopic findings, including the presence of a fistula tract.

Acute Compartment Syndrome in the Setting of Weight Loss Supplements and Exercise-Induced Rhabdomyolysis.

The growing prevalence of obesity in the USA has resulted in increased consumption of weight loss products that promote fat metabolism. Dietary supplements used for weight loss contain a wide variety of ingredients but the amount of scientific information available on these ingredients varies considerably. Such supplements have documented and undocumented adverse effects. Although the FDA frequently issues health advisories, the health consequences of consuming supplements are often overlooked by the general public. A common supplement used for weight loss is Hydroxycut. The ingredients used in the different forms of Hydroxycut products vary but generally include caffeine and green tea extract, which are responsible for a wide range of adverse effects. We present the case of 41-year-old man with a medical history of polysubstance abuse who developed acute compartment syndrome in the setting of rhabdomyolysis from prolonged immobilisation and the use of Hydroxycut. This case demonstrates the possible adverse effects of consuming weight loss herbal supplements like Hydroxycut. Healthcare professionals and consumers are encouraged to report serious adverse events or product quality problems with the use of these supplements to the FDA's MedWatch adverse event reporting program. LEARNING POINTS: The weight loss supplement Hydroxycut is sold in various formulations whose side effect profiles are not fully known; the latest formulation has a very high concentration of caffeine which increases the risk of rhabdomyolysis.Although uncommon, exercise-induced rhabdomyolysis can cause compartment syndrome, especially in the setting of concurrent use of weight loss supplements.High clinical suspicion, prompt diagnosis and early treatment are key to preventing complications from compartment syndrome.