Suspected Levetiracetam-Induced Rhabdomyolysis: A Case Report and Literature Review.

BACKGROUND Levetiracetam (LEV) is an anticonvulsant commonly used for treatment of generalized and partial seizure disorder. Some of the common side effects associated with levetiracetam include somnolence, dizziness, headaches, and mood changes. Rhabdomyolysis and increase in creatine kinase (CK) levels is one of the rarely reported effects of LEV. CASE REPORT We report a case of a 22-year-old man admitted for evaluation of new-onset generalized tonic-clonic seizures. The patient was started on levetiracetam 500 mg twice a day, after which his CK levels started to increase, with maximum level of 21 936 IU/L noted on day 5. No improvement in CK levels was observed even with aggressive intravenous hydration. In the absence of any other obvious cause, the persistent elevation in patient's CK levels was suspected to be due to LEV. Our suspicion was supported by significant decrease in CK levels (from 21 936 IU/L to 11 337 IU/L) after about 30 h of discontinuation of LEV. We reviewed cases of LEV-induced rhabdomyolysis reported in the literature over the last decade and found 13 cases with almost similar correlation between initiation of LEV and increase in CK levels. CONCLUSIONS Our case report stresses the importance of close monitoring of CK levels and kidney functions after initiation of LEV, and to consider changing the anticonvulsant medication if CK levels are noted to be significantly high to avoid kidney injury.

Orthostatic Hypotension, Cardiovascular Outcomes, and Adverse Events: Results From SPRINT.

Orthostatic hypotension (OH) is frequently observed with hypertension treatment, but its contribution to adverse outcomes is unknown. The SPRINT (Systolic Blood Pressure Intervention Trial) was a randomized trial of adults, age ≥50 years at high risk for cardiovascular disease with a seated systolic blood pressure (BP) of 130 to 180 mm Hg and a standing systolic BP ≥110 mm Hg. Participants were randomized to a systolic BP treatment goal of either <120 or <140 mm Hg. OH was defined as a drop in systolic BP ≥20 or diastolic BP ≥10 mm Hg 1 minute after standing from a seated position. We used Cox models to examine the association of OH with cardiovascular disease or adverse study events by randomized BP goal. During the follow-up period (median 3years), there were 1170 (5.7%) instances of OH among those assigned a standard BP goal and 1057 (5.0%) among those assigned the intensive BP goal. OH was not associated with higher risk of cardiovascular disease events (primary outcome: hazard ratio 1.06 [95% CI, 0.78-1.44]). Moreover, OH was not associated with syncope, electrolyte abnormalities, injurious falls, or acute renal failure. OH was associated with hypotension-related hospitalizations or emergency department visits (hazard ratio, 1.77 [95% CI, 1.11-2.82]) and bradycardia (hazard ratio, 1.94 [95% CI, 1.19-3.15]), but these associations did not differ by BP treatment goal. OH was not associated with a higher risk of cardiovascular disease events, and BP treatment goal had no effect on OH's association with hypotension and bradycardia. Symptomless OH during hypertension treatment should not be viewed as a reason to down-titrate therapy even in the setting of a lower BP goal. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT01206062.

Prevalence and specificity of clinically significant red cell alloantibodies in pregnant women - a study from a tertiary care hospital in Southeast Michigan.

BACKGROUND: Maternal red cell IgG antibodies can cross the placenta and cause hemolysis of fetal red cells in case of antigenic differences between maternal and fetal RBCs, leading to hemolytic disease of the fetus and newborn (HDFN). Although the incidence of anti-D associated HDFN has drastically reduced with Rh immune globulin prophylaxis, HDFN due to other maternal red cell alloantibodies still remains a concern. Prevalence and specificities of clinically significant red cell alloantibodies in pregnant females have rarely been reported in the USA. METHODS: A retrospective chart review was conducted to determine the prevalence and specificity of clinically significant red cell alloantibodies in pregnant females who delivered at Beaumont Hospital Royal Oak between May 1, 2017 and December 31, 2017. A total of 4548 pregnant females were screened using electronic medical records. One female above 50 years age and two females with invalid ABO type were excluded from the study per IRB approved protocol. The remaining 4545 pregnant females with a valid ABO/RhD type and valid red cell antibody screen were included. RESULTS: Out of the 4545 included females, 440 had a positive red cell antibody screen. Of these 440 females, 34 had clinically significant alloantibodies, giving an overall prevalence of 0.74%. Anti-E was the most frequently identified significant alloantibody followed by anti-K. The most prevalent significant alloantibodies in RhD positive and RhD negative females were anti-E and anti-K, respectively. Significant association (p-value <0.001) was found between RhD type and the presence of clinically significant alloantibodies amongst females with positive antibody screen. CONCLUSION: Our study aims to reiterate the importance of maternal red cell antibody screening during early pregnancy to help identify and manage high-risk pregnancies. Minimizing the exposure of childbearing age females to incompatible red cell antigens through unnecessary transfusions can help reduce the incidence of red cell alloimmunization and the risk of HDFN.

Acute Intravascular Hemolysis Following an ABO Non-Identical Platelet Transfusion: A Case Report and Literature Review.

BACKGROUND Platelet transfusion is a common clinical practice required for therapeutic purposes in the setting of symptomatic thrombocytopenia, and, in some cases, prophylactically for asymptomatic thrombocytopenia. Crossmatch compatibility is not routinely done for platelet transfusions, and transfusion of ABO non-identical platelets has been adapted as an acceptable clinical practice. Acute intravascular hemolysis due to ABO non-identical platelets is a rare but clinically significant entity. Our case report reinforces the importance of a vigilant clinical approach in case of ABO non-identical platelet transfusions. CASE REPORT We report the case of 61-year-old woman with blood group A, with chemotherapy-induced asymptomatic thrombocytopenia, who developed acute intravascular hemolysis following transfusion of group O single-donor platelets (SDPs). The patient was transfused 1 unit of single-donor platelets for bleeding prophylaxis, as her platelet count dropped to less than 10×109/L due to chemotherapy that she was receiving for acute myeloid leukemia (AML). Immediately after transfusion, the patient noticed cherry-colored urine; and within 12 h of transfusion, her hemoglobin dropped by more than 2.5 g/dL. A post-transfusion immunohematology work-up showed positive DAT and high titers of anti-A1 isohemagglutinins in the platelet donor, supporting the diagnosis of acute intravascular hemolysis due to ABO non-identical platelets. CONCLUSIONS The possibility of acute intravascular hemolysis should be kept in mind in cases of transfusion of group O single donor platelets to non-group O recipients. ABO non-identical platelets, even with low isohemagglutinin titers, can cause significant adverse effects, particularly in newborns, children, and immunosuppressed and transfusion-dependent patients; therefore, a cautious clinical approach is recommended.

Prophylaxis against venous thromboembolism in hospitalized medical patients: an evidence-based and practical approach.

To discuss the evidence regarding the efficacy and safety of anticoagulant prophylaxis against deep vein thrombosis (DVT) in hospitalized medical patients; to understand barriers to implementation of prophylaxis and how they can be overcome; and to have a practical approach as to which patients should and should not receive anticoagulant prophylaxis. The frequency of DVT in hospitalized medical patients, in the absence of prophylaxis varies from 10-15%. Autopsy studies have shown that pulmonary embolism (PE) is associated with 5-10% of deaths in hospitalized patients. With appropriate use of anticoagulant prophylaxis, there is a 57% reduction in the risk for symptomatic PE (relative risk [RR] 0.43, 95% CI 0.26-0.71), a 62% reduction in the risk for fatal PE (RR 0.38, 95% CI 0.21-0.69), and a 53% reduction in the risk for symptomatic DVT (RR 0.47, 95% CI 0.22-1.00). Anticoagulant prophylaxis is also associated with a non-significant increased risk for major bleeding (RR 1.32, 95% CI 0.73-2.37). Risk factors for DVT and bleeding in medical patients may help to identify patients in whom anticoagulant prophylaxis is indicated or contraindicated but validated risk stratifications schemes are lacking. Among hospitalized medical patients, randomized trials have established an acceptable therapeutic benefit-to-risk ratio of anticoagulant prophylaxis to reduce the incidence of clinically silent and symptomatic venous thromboembolism, including a reduction in the incidence of fatal PE. Additional research is needed to develop a validated risk stratification model for hospitalized medical patients that can help identify patients who would benefit most from anticoagulant prophylaxis.