A Rare Case of Acute Methotrexate Toxicity Leading to Bone Marrow Suppression.

Methotrexate is a first-line disease modifying antirheumatic drug used for the treatment of inflammatory arthritis. Bone marrow suppression is a common adverse reaction of methotrexate following its long-term use. However, low dose methotrexate is rarely associated with life-threatening bone marrow suppression. This case represents an atypical presentation of acute bone marrow suppression shortly after initiating treatment with low-dose methotrexate. A 76-year-old male patient presented with oral ulcers, poor oral intake, and acute kidney injury within 3 weeks of initiating 15 mg weekly of methotrexate for seronegative rheumatoid arthritis. Complete blood count was suggestive of pancytopenia with hemoglobin of 10.8 g/dL, total white cell count 3.36 (1000/uL) (absolute neutrophil count 490 micro/L), platelets 19,000, serum albumin 3.1 g/dL, ESR elevated at 83 mm/hr, CRP elevated at 86.6 mg/L, and ferritin mildly elevated at 625 ng/mL. Peripheral blood smear showed signs of bone marrow suppression but no signs of hemolysis or inflammation. Serum methotrexate levels were minimally detectable at 0.05 umol/L. Methotrexate was held, within 48 hours of admission; his WBC dropped to 1.48, Hgb 9.9, and platelets 15,000. ANC reached a nadir of 220. He was treated with broad spectrum antibiotics, high-dose folic acid, fluconazole for oral thrush, and intravenous bicarbonate and leucovorin supplementation, dosed at PO 20 mg daily. On day 7, his blood count showed improvement along with improvement in his symptoms. The patient was discharged home on day 8th of hospitalization and upon one month follow-up in rheumatology clinic, his complete blood count had normalized. This case highlights multiple risk factors that triggered pancytopenia in our elderly patient, resulting in acute methotrexate toxicity.

A Case of Severe Multisystem Inflammatory Syndrome in Children (MIS-C) Treated with Multiple Biologics.

The COVID-19 virus has impacted global health on a wide scale, affecting humans of all ages and ethnicities. While most have mild upper respiratory viral symptoms, some have died due to severe pneumonia, acute respiratory distress syndrome (ARDS), or coagulopathies to mention a few. It has been postulated that the COVID-19 virus can initiate an autoinflammatory reaction in the body via multiple pathways of cytokine activation. The virus can cause delayed response after 4-8 weeks of acute infection, which resembles a cytokine storm or MAS (macrophage activation syndrome). This highly inflammatory syndrome, called MIS-C or multisystem inflammatory response syndrome, needs to be diagnosed and treated early to prevent multiorgan damage and mortality. There are widespread lab abnormalities including highly elevated acute phase reactants ferritin, D-Dimer, lactate dehydrogenase (LDH), creatinine kinase (CK), sedimentation rate (ESR), and C-reactive protein (CRP) as well as markers of cardiac damage including troponin and brain natriuretic peptide (BNP). The syndrome can present in unique ways from classic MIS-C with hypovolemic shock to Kawasaki disease-like presentation. We present a case of a 12-year-old boy who presented to Le Bonheur Children's Hospital in Memphis with classic signs and symptoms of "severe" MIS-C requiring intubation, multiple pressors, ECMO, and renal replacement therapy. He was treated successfully with immunomodulating medicines including intravenous immune globulin (IVIG), steroids, interleukin-6 inhibitor, tumor necrosis factor-a inhibitor, interleukin-1 inhibitor, and Janus kinase inhibitor.

A Case of Anti-Jo-1 Myositis with Unique Biopsy Findings.

Antisynthetase syndrome (ASS) or anti-Jo-1 antibody syndrome has a classic clinical presentation including arthritis, myositis, interstitial lung disease, mechanic hands, and/or Raynaud's phenomenon. The biopsy findings are distinctive from polymyositis or dermatomyositis. We describe an interesting case of ASS where a patient presented with significant muscle weakness, proteinuria, and interstitial lung disease. She also had positive Ro-52 antibodies in addition to anti-Jo-1 antibodies. Her biopsy findings were consistent with inflammatory necrotizing myositis.

Subclinical Hypothyroidism and Its Association with Increased Cardiovascular Mortality.

Thyroid hormones play an important role in regulating different metabolism functions and multiple organs' performance. Changes in the thyroid hormone axis can lead to profound effects on the stability of vital organs and systems, especially the cardiovascular system. Hypothyroidism is classified according to the clinical presentation as overt and subclinical. There is some evidence supporting the benefits of thyroxine hormone replacement for subclinical hypothyroidism on cardiovascular mortality outcomes. However, the clinical relevance of measuring and treating high thyroid-stimulating hormone (TSH) levels in newly diagnosed heart failure patients with preserved ejection fraction requires further study. In this report, we review the current evidence regarding the prognostic significance of subclinical hypothyroidism in heart failure patients with preserved ejection fraction.

Diffuse Idiopathic Skeletal Hyperostosis: Persistent Sore Throat and Dysphagia in an Elderly Smoker Male.

Diffuse idiopathic skeletal hyperostosis (DISH) is rarely symptomatic. However, it can present with dyspnea, hoarseness, dysphagia, and stridor. An 80-year-old chronic smoker male presented with 6-month history of sore throat and progressive dysphagia. Computed tomography of the neck revealed bulky anterior bridging syndesmophytes along the anterior aspect of the cervical spine and facet effusion involving four contiguous vertebrae consistent with DISH. Dysphagia secondary to DISH was diagnosed. Fiberoptic laryngoscopy showed bilateral vocal cord paralysis. Patient's airway became compromised requiring tracheostomy tube placement. After discussion of therapeutic options, patient agreed on a percutaneous endoscopic gastrostomy tube insertion for nutritional support. Osteophytectomy was left to be discussed further.

Cerebral toxoplasmosis requiring urgent brain biopsy.

A 39-yerar-old man was admitted to our hospital with behavioral disturbances and generalized headaches. He was diagnosed with CNS toxoplasmosis after performing a brain biopsy. He found to be HIV positive with a CD4 of 14/uL He was started on ant toxoplasmosis along with antiretroviral therapy. He presented 6 weeks after discharge with worsening headache thought to be related to relapse of toxoplasmosis. However, he found to have severe anemia related to CMV-induced gastrointestinal bleeding. He was started on anti-cytomegalovirus drugs and has finally achieved significant improvement.

Sub-Clinical Hypothyroidism and Its Association With Increased Cardiovascular Mortality: Call for Action.

Thyroid hormones play an important role in regulating different functions regarding metabolism and performance in multiple organs. Any change in the thyroid hormones axis can lead to profound effect on the vital organ stability especially the cardiovascular system. Hypothyroidism is classified according to the clinical presentation as overt and subclinical. Currently, there exists a paucity of evidence on the beneficial effects of thyroxine hormone replacement on cardiovascular mortality outcomes in subclinical hypothyroidism. Also, the clinical relevance of measuring and treating supra-normal thyroid-stimulating hormone levels in newly diagnosed heart failure patients with preserved ejection fraction requires further study. Here we review the current evidence regarding the prognostic significance of sub-clinical hypothyroidism in patients with heart failure with preserved ejection fraction.

Effects of inflow of inpatients attendants at a tertiary care hospital--a study at civil hospital Karachi.

OBJECTIVE: To assess the trend of attendants accompanying inpatients and its effect on a tertiary care hospital in Karachi. METHODS: A cross sectional study was carried out at CHK, through interview-based questionnaires targeting three groups of interest viz. patients admitted in the wards and stable enough to answer questions appropriately, attendants residing at CHK premises and heads of hospital departments or administrative Resident Medical Officers. RESULTS: Out of 281 patients, 149 (53.03%) had only one attendant staying with them, 74 (26.34%) had two, 39 (13.88%) had more than two and 19 (6.76%) had none. Out of 240 attendants, 204 (85%) planned to stay within the hospital till discharge of their patient while 24 (10%) till a week and 12 (5%) for two weeks. Out of 21 administrative heads, 18 (85.71%) faced problems due to presence of extra attendants and 3 (14.29%) did not. However, all 21 (100%) agreed that there were risks associated with presence of too many attendants; which were financial burden 13 (61.9%), infections 14 (66.67%), physical violence 11 (52.38%), disturbance of hospital sanctity 13 (61.91%), and crimes 10 (47.62%). CONCLUSION: Our study suggested that there was a significant trend for patients to be accompanied by multiple attendants at CHK. Although hospital did not have to provide food and shelter to them, but their presence in large numbers was in violation to hospital protocols. In view of the hospital administration multiple attendants caused hindrance in duties of staff and posed infections and security risks.

Use of smoke-less tobacco amongst the staff of tertiary care hospitals in the largest city of Pakistan.

BACKGROUND: Use of smoke-less tobacco (SLT) is very common in South and South-East Asian countries. It is significantly associated with various types of cancers. The objectives of this study were to assess the proportion of hospital staff that use SLT, and to identify the factors associated with its use and their practices. METHODS: In a cross-sectional study, 560 staff of two tertiary care hospitals were interviewed in the year 2009. Nurses, ward boys and technicians were counted as a paramedic staff while drivers, peons, security guards and housekeeping staff were labeled as non-paramedic staff. SLT use was considered as usage of any of the following: betel quid (paan) with or without tobacco, betel nuts with or without tobacco (gutkha) and snuff (naswar). RESULTS: About half (48.6%) of the hospital staff were using at least one type of SLT. Factors found to be statistically significant with SLT were being a male (OR=2.5; 95% CI=1.8-3.7); having no/fewer years of education (OR=1.7; 95% CI=1.2-2.4) and working as non-paramedic staff (OR=2.6; 95% CI=1.8-3.8). Majority of SLT users were using it on regular basis, for >5 years and keeping the tobacco products in the oral cavity for >30 minutes. About half of the users started due to peer pressure and had tried to quit this habit but failed. CONCLUSION: In this study, about half of the study participants were using SLT in different forms. We suggest educational and behavioral interventions for control of SLT usage.