Severe Thrombocytopenia Two Weeks Following Immunization with the Janssen Ad26.CoV2.S Vaccine.

Immune thrombocytopenia (ITP) has been associated with immunizations with various proposed mechanisms, including overactivation of the immune system and production of antibodies against circulating platelets. ITP has also been associated with several viral infections, including HCV, HIV, and most recently, active SARS-CoV-2 infection. Here, we present a case of a 52-year-old male with no past medical history who sought evaluation with his primary care physician for upper and lower extremity ecchymosis of one week duration. Outpatient laboratory studies were notable for severe isolated thrombocytopenia with platelet count of 8 × 10^9/L. Interestingly, he received the Johnson and Johnson COVID-19 vaccine 16 days prior to his presentation. Clinical work up and laboratory investigations led to the diagnosis of ITP.

Use of circulating tumour DNA in nasopharyngeal carcinoma to detect minimal residual disease.

Circulating tumour DNA (ctDNA) is defined as short DNA sequences shed by tumour cells into the systemic circulation. A promising use of ctDNA includes the detection of minimal residual disease (MRD) and is currently being studied in multiple types of solid tumours. Literature for the use of individualised ctDNA in nasopharyngeal carcinoma (NPC) is not available, although circulating Epstein-Barr virus DNA level is validated as a prognostic factor. We present a man in his 40s diagnosed with stage IV NPC who was started on chemotherapy with cis-platinum and gemcitabine. Serial monitoring of ctDNA completed to aid in detecting MRD after treatment demonstrated initial up-trending values correlating with subsequent imaging findings showing progression. Reinitiation of a different chemotherapy regimen significantly improved the ctDNA level, with corresponding imaging exhibiting a similar response. This case provides insight into the potential use of ctDNA in NPC and the benefit of serial ctDNA monitoring during treatment.

Thrombotic thrombocytopenic purpura following administration of the Moderna booster vaccine.

Thrombotic thrombocytopenic purpura (TTP) is a type of thrombotic microangiopathy that is characterized by microangiopathic haemolytic anaemia, consumption thrombocytopenia and organ injury. It is caused by a severe deficiency of ADAMTS13, which can be either congenital or acquired. There is a plethora of things that can cause the acquired form, including medications and infections. Vaccines have also been shown to cause TTP. In the midst of the COVID-19 pandemic, with multiple new vaccines being developed and distributed to the masses, the medical community needs to be aware of adverse events associated with these new vaccines. We present a case of TTP following administration of the Moderna booster vaccine.

Analysis of risk factors contributing to morbidity from gastrojejunostomy feeding tubes in children.

PURPOSE: The purpose of this study was to define morbidity from gastrojejunostomy tube (GJT) placement in children. METHODS: A retrospective single-center 5-year review of GJT placement in children was performed. Age, weight, prior surgery, indication, type of GJT, and complications (GJT replacement, wound complications, and perforation) were recorded. Logistic regression for morbidity was performed. RESULTS: 142 children underwent 394 GJT placements at a median age of 2.7years (range 5 weeks-18years). The most common indications were failure to thrive (62%) and reflux (25%). Among the 296 GJT replacements, the most common reason was tube dislodgement (30%). Risk factors for replacement, which occurred at a median interval of 12 weeks (range 2days-2.4years), were peristomal complaint (OR=5.4, p=0.02) and prior GJT replacement (OR=1.8, p=0.03). In all, 7 (5%) jejunal perforations occurred at a median of 3 days (range 0-21 days) from GJT placement. Patients with perforation had a median weight of 4.6kg (range 3-11.2kg) and age of 3.9months (range 8 weeks-2.1years). Lower weight (p<0.01) and younger age (p=0.02) predicted perforation, with those weighing less than 6kg (OR=51.9, p<0.001) or younger than 6months (OR=28.6, p<0.01) at highest risk. CONCLUSIONS: GJT placement has a significant risk of recurrent dislodgement and the highest risk of perforation in children weighing less than 6kg or younger than 6months. Alternate feeding options should be strongly considered in this vulnerable population.

Enteral autonomy in pediatric short bowel syndrome: predictive factors one year after diagnosis.

PURPOSE: This study examined predictors of achieving enteral autonomy among pediatric short bowel syndrome (SBS) patients remaining on parenteral nutrition (PN) beyond one year. METHODS: A retrospective single-institution study of 171 pediatric SBS patients (defined as ≥50% small bowel (SB) loss or ≥60 days of PN with onset before 6 weeks of age) was performed. Multivariate Cox proportional hazards analysis was conducted, with subgroup analysis of patients on PN for ≥1 year (n=59). Primary outcome was successful wean from PN. RESULTS: Over a follow-up of 4.1±4.8 years, 64.3% of children weaned from PN. Mortality was 15.2%. Presence of ≥10% expected SB length (hazard ratio [HR] 6.48, p=0.002) or an ileocecal valve (ICV; HR, 2.86, p<0.001) predicted PN weaning. Of those on PN ≥1 year, the wean rate was 50.8%, and ICV no longer predicted weaning (p=0.153). Predictors among those on PN ≥1 year were: ≥10% expected SB length (HR, 8.27, p=0.010), intestinal atresia (HR, 4.26, p=0.011), and necrotizing enterocolitis (NEC, HR, 2.84, p=0.025). CONCLUSIONS: SBS children on PN ≥1 year continue to wean from PN, and those with ≥10% of predicted SB length, NEC, or atresia are more likely to do so. These findings may help direct management and advice for these challenging patients.