COVID-19-induced immune thrombocytopenia management approach: A case report and literature review.

Key Clinical Message: Vincristine therapy can be effective in refractory Immune thrombocytopenia (ITP) following COVID-19 vaccination. Our case report highlights the need for further research to establish standard management guidelines for COVID-19-vaccine-associated ITP. Abstract: Adult immune thrombocytopenia (ITP) can occur as a rare complication following several viral infections or a rare adverse event or complication of vaccination. In this paper, we report a case of a 39-year-old male patient with severe refractory ITP that began 4-weeks after receiving his third (booster) dose of the COVID-19 vaccine (BNT162b2, Pfizer-BioNTech). He was given oral dexamethasone 40 mg daily for 4 days followed by prednisone at 1 mg/kg (85 mg daily) for 10 days. In the following weeks, we attempted several other lines of therapy to treat his ITP, including anti-RhD immunoglobulin, which, unfortunately, caused moderate hemolysis requiring packed red blood cell transfusion, intravenous immunoglobulin (given at a subtherapeutic dose of 0.4 g/kg for only 1 day since it was not available), rituximab, and eltrombopag. The patient, unfortunately, showed no response to any of these treatments. This was an indicator to initiate salvage therapy with vincristine 2 mg weekly for 3 weeks. The patient's platelet count started to increase remarkably during the third week of vincristine and normalized after 4 weeks. We review the findings, clinical characteristics, and management approaches that were reported in the literature regarding COVID-19-vaccine-induced ITP. More in-depth research is needed to delineate standard guidelines for the management of such cases. This report underscores the importance of resorting to vincristine and eltrombopag as great options for severe and refractory ITP related to the COVID-19 vaccine.

Cardiovascular Consequences of Sickle Cell Disease.

Background: Sickle cell disease is an inherited blood disorder which can lead to severe complications, particularly in the cardiovascular and respiratory systems, potentially resulting in arrhythmias, pulmonary hypertension (PH), and cardiomegaly. This study aims to investigate the risk of PH and arrhythmias in adult SCD patients. Methods: Retrospective analysis of medical records from King Abdulaziz University Hospital (KAUH) for patients with SCD aged 15 and above between 2009 and 2021. The study included 517 patients, with echocardiograms and electrocardiograms assessed according to the European Society of Cardiology/the European Respiratory Society (ESC/ERS) guidelines for categorizing PH risk (low, moderate, high) and detecting arrhythmias. Data analysis employed the Statistical Package for the Social Sciences (SPSS), utilizing quantitative and qualitative data representation. Multivariate logistic regression identified independent risk factors with odds ratios at a 95% confidence interval (CI). Results: Among participants, 50.3% were male, with a total sample average age of 34.45 ± 9.28 years. Results indicated that 1.4% of patients experienced arrhythmias, 3.7% had a moderate PH risk, and 3.3% were classified as high PH risk. Logistic regression revealed significant independent risk factors for PH and arrhythmia in patients with SCD, with chronic kidney disease (CKD) carrying the highest odds (26.4 times higher odds of PH and 15.36 times higher odds of arrhythmias). Conclusion: Patients with SCD are at risk for developing PH and various arrhythmias but are often underdiagnosed. Key risk factors for PH included CKD, liver cirrhosis, and pre-existing cardiac conditions. Arrhythmias were significantly associated with CKD and pre-existing cardiac conditions. To mitigate these risks, we recommend involving a multidisciplinary healthcare team in the care of adult patients with SCD. Future prospective studies are advised for early detection of PH and arrhythmias in hemoglobinopathy patients, potentially reducing mortality.

Profiling of microRNAs by next-generation sequencing: Potential biomarkers for diffuse large B-cell lymphoma.

Background: Lymphoma ranks fifth in prevalence among common cancer types worldwide. This lymphatic system cancer arises from T or B cells. Diffuse large B cell lymphomas (DLBCLs) are associated with most non-Hodgkin lymphomas. Non-coding microRNAs (miRNAs) greatly affect gene expression. A single miRNA can target numerous genes, thus largely influencing gene expression networks. MiRNAs can act as oncogenes or tumor suppressors in controlling DLBCL progression. This study investigated the roles of miRNAs in patients with DLBCL through next-generation sequencing, which was found to be sensitive, accurate, and robust. Methods: The study involved seven patients with DLBCLs and three controls at a hematology-oncology clinic. MiRNA was extracted from existing formalin-fixed, paraffin-embedded (FFPE) tissue specimens. Illumina next-generation sequencing was used to sequence samples for miRNA profiling. Results: Samples from patients showed expression of various hsa-mir miRNAs (1248, 3607, 21, 142, 1244, 182, 6516, 766, 1291, 4449, and 181a), whereas those from healthy individuals showed expression of hsa-mir 1248, 3607, 21, 142, and 877. Hsa-mir-877-3p is known to target multiple genes, and miRNAs such as hsa-mir-877-3p, hsa-mir-1291, and hsa-mir-181a-5p interact primarily with target genes. Conclusions: MiRNA profiling in FFPE tissues from patients with DLBCL suggested that miRNA levels can distinguish patients with DLBCL from controls, and therefore may provide prognostic or diagnostic biomarkers for DLBCL. Altered genes and miRNAs may also be potential therapeutic targets.

Predisposing Factors and Incidence of Venous Thromboembolism among Hospitalized Patients with Sickle Cell Disease.

Though patients with sickle cell disease (SCD) are at risk of developing venous thromboembolism (VTE), clear estimates of its incidence and predisposing factors in hospitalized SCD patients are not available. Therefore, this issue was addressed to facilitate an early diagnosis and initiate appropriate prophylactic and treatment strategies. A retrospective observational study was conducted on patients with SCD who were admitted to an academic center in Saudi Arabia over a 10-year period. We identified 1054 admissions of 394 patients with SCD. Of the 3% of patients identified with VTE, 50% experienced pulmonary embolism (PE), 34.3% exhibited deep vein thrombosis (DVT), 6.3% exhibited cerebral vein thrombosis, and 9.4% showed other forms of VTE. In pregnant SCD patients, 6.4% developed a VTE event during their hospital admission. Of the risk factors, high white blood cell count, length of stay, and presence of any additional risk factor for VTE was associated significantly with higher risk of VTE. In our study, this risk seems to be much lower, which is likely attributed to the use of VTE prophylactic strategies implemented in our center. Nevertheless, further studies are needed to establish the ideal prophylactic strategy in patients with SCD.

Association of Genetic Variant FVIII Gene and Factor VIII: A Pilot Study Among Hemophilia A Female Relatives in Saudi Arabia.

Hemophilia A (HA) is an X-linked recessive disorder that results from mutations in the factor VIII gene (FVIII). Most affected patients are males due to the inheritance of mutations in the FVIII gene from their mothers. Females are mostly found to be carriers unless they inherited the mutation from both parents. Obligate carriers of HA are mothers whose sons are affected with HA, or daughters who inherit the mutation from their affected fathers. A possible carrier of HA could be any female who has one or more affected relatives with HA in her family. Hemophilia A carriers (HACs) could present with similar symptoms to affected patients, including low factor VIII level, and risk of bleeding especially after surgical procedures or postpartum hemorrhage. OBJECTIVES:  Assessing the phenotype of possible HAC and its association with genetic variants in the FVIII gene for better screening methods for HAC. METHODS: From the period between 25 June and 25 October 2021, the study was conducted at King Abdulaziz University Hospital in Jeddah, Saudi Arabia. We recruited seven mothers whose sons were affected with HA, and 18 possible HAC who are relatives to sever affected patients with HA. All 25 candidates were assessed for the FVIII level, activated partial thromboplastin time (APTT), and bleeding risk and sequenced a part of Exon14 in their FVIII gene. RESULTS: Twenty-five percent of the participants show a low level of FVIII, however, none of them have prolonged bleeding nor suffer from bleeding tendency. We also identified two missense variants in six of the candidates, but the clinical significance of these variants has not been determined previously. CONCLUSION: This pilot study is the first to explore the phenotype of several HAC in Saudi Arabia. A larger scale study with more HA patients and their female relatives is needed to understand the correlation between phenotype and genotype for better screening for HAC.

Blastocystis sp.-An emerging cause of diarrhea post stem cell transplantation.

Key Clinical Message: Protozoans are endemic in the Middle East and diarrhea workup post stem cell transplant should always include stool examination for ova and parasites. Abstract: We present a case of Blastocystis sp. infection in a multiple myeloma patient who developed diarrhea on day five of post-autologous stem cell transplantation. Diarrhea is a major complication and a potential cause of mortality in this population. Testing for endemic protozoan is recommended.

Impact of COVID-19 Crisis in the Management of Diabetic Foot Patients in King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

Background The COVID-19 pandemic has a heavy burden on the approach of diabetic foot care worldwide. We aim to determine the impact of the COVID-19 outbreak on patients with diabetic foot (DF). Materials and methods This population-based cohort study included all patients diagnosed with the diabetic foot from 2019-2020 (pre-lockdown) and 2020-2021 (post-lockdown) in a tertiary center of Jeddah, Saudi Arabia. Results Among all the participants (n=358), a non-significant difference was found between amputation rate during and before the COVID-19 pandemic (P-value=0.0983). Also, it showed a significantly higher percentage of patients who had acute lower limb ischemia compared to those having it before the pandemic (P-value=0.029). Conclusions and relevance In conclusion, our study found that the COVID-19 pandemic was not associated with excess amputations along with mortality rate, as the management during the pandemic showed adequate diabetic foot care by improving the prevention methods through hospital protocol restrictions and facilitating access to virtual clinics.

Incidence and Risk Factors of Infections Among Diffuse Large B-cell Lymphoma and Classical Hodgkin's Lymphoma Patients in a Tertiary Care Center in Saudi Arabia: A Retrospective Cohort Study.

INTRODUCTION:  Non-Hodgkin's lymphoma (NHL) ranked fourth among all cancer types in Saudi Arabia, as reported by the Saudi Health Council in 2015. Diffuse large B-cell lymphoma (DLBCL) is the most common histological type of NHL. On the other hand, classical Hodgkin's lymphoma (cHL) ranked sixth and had a modest tendency to affect young men more frequently. Over recent decades, DLBCL patients were treated with cyclophosphamide, doxorubicin hydrochloride, oncovin, and prednisolone (CHOP) alone. Adding rituximab (R) to the standard regimen (CHOP) shows significant improvement in overall survival. However, it also has a considerable effect on the immune system, impacting complement-mediated and antibody-dependent cellular cytotoxicity and causing an immunosuppressive state through modulating T-cell immunity via neutropenia, which can let the infection spread. AIMS AND OBJECTIVES:  This study aims to evaluate the incidence and risk factors associated with infections in DLBCL patients in comparison to patients with cHL treated with doxorubicin hydrochloride (Adriamycin), bleomycin sulfate, vinblastine sulfate, and dacarbazine (ABVD). MATERIALS AND METHODS:  This study is a retrospective case-control study that included 201 patients acquired between January 1st, 2010, and January 1st, 2020. Sixty-seven patients had a diagnosis of cHL and had received ABVD, and 134 had DLBCL and had received rituximab. Clinical data were obtained from the medical records. RESULTS:  During the study period, we enrolled 201 patients, of whom 67 had cHL, and 134 had DLBCL. DLBCL patients had a higher serum lactate dehydrogenase upon diagnosis than cHL (p = 0.005). Both groups have similar response rates with complete remission/partial remission. Compared to cHL, patients with DLBCL were more likely to have advanced disease when they first presented (stage III/IV, DLBCL: 67.3 vs. cHL: 56.5; p = 0.005). DLBCL patients had an increased risk of infection as compared to cHL patients (DLBCL: 32.1 % vs. 16.4%; p = 0.02). However, patients with a poor response to treatment had an increased risk of infection compared to patients with a favorable response regardless of the type of disease (odds ratio: 4.6; p = <0.001). When using multivariate analysis, it is revealed that unfavorable therapeutic response continues to be the only predictor raising the probability of infection in the population (odds ratio: 4.2; p = 0.003). CONCLUSIONS:  Our study explored all potential risk factors for the occurrence of infection in DLBCL patients who received R-CHOP versus cHL. The most reliable predictor of an increased risk of infection during the follow-up period was having an unfavorable response to medication. To assess these results, additional prospective research is required.

Antiphospholipid Antibody Testing: An Audit on Testing Practices in a Public Tertiary Care Center.

BACKGROUND: Antiphospholipid antibodies (aPLs) are antibodies directed against cell membrane components and can be associated with clinical features or be asymptomatic. Testing and interpreting these antibodies is associated with many challenges and pitfalls in clinical practice. OBJECTIVE: To review all antiphospholipid antibody testing and describe the testing practices, indications for testing and interpretation of results to infer local challenges with aPL testing and subsequently address ways to overcome those challenges. METHODS: This is a retrospective analysis of all aPL testing done in a tertiary center between 2014 and 2018. Characteristics of study patients collected through chart review were described using the mean and standard deviation for continuous variables and proportion for categorical variables. Group differences were compared between patients with any aPL-positive result and those with no positive result using chi-square or Fisher's exact test as appropriate for categorical variables and a simple regression model for numerical variables. RESULTS: Among 414 patients undergoing aPL testing, mainly adult females, 62 (14.9%) patients had at least one positive antibody, of those, 26 (42%) had repeat testing done. Testing was mostly done for obstetric indication (107, 25.8%), with 36 patients having one or two early pregnancy losses <10 weeks as their testing indication. A total of 27 (6.5%) patients were labeled with APS/possible APS based on chart review, but on review of the testing of those patients according to classification criteria, only nine patients satisfied the criteria for APS. CONCLUSION: This study highlights the clinical challenges associated with aPL testing, including the controversies around indication for testing, the low rates of repeat testing to confirm persistence, and the common misinterpretation of results. Having an aPL testing profile, explicit reference ranges, results commentary, and close interaction between ordering physicians and laboratory staff might be starting points to overcome these challenges.

Revealing brain connectivity: graph embeddings for EEG representation learning and comparative analysis of structural and functional connectivity.

This study employs deep learning techniques to present a compelling approach for modeling brain connectivity in EEG motor imagery classification through graph embedding. The compelling aspect of this study lies in its combination of graph embedding, deep learning, and different brain connectivity types, which not only enhances classification accuracy but also enriches the understanding of brain function. The approach yields high accuracy, providing valuable insights into brain connections and has potential applications in understanding neurological conditions. The proposed models consist of two distinct graph-based convolutional neural networks, each leveraging different types of brain connectivities to enhance classification performance and gain a deeper understanding of brain connections. The first model, Adjacency-based Convolutional Neural Network Model (Adj-CNNM), utilizes a graph representation based on structural brain connectivity to embed spatial information, distinguishing it from prior spatial filtering approaches dependent on subjects and tasks. Extensive tests on a benchmark dataset-IV-2a demonstrate that an accuracy of 72.77% is achieved by the Adj-CNNM, surpassing baseline and state-of-the-art methods. The second model, Phase Locking Value Convolutional Neural Network Model (PLV-CNNM), incorporates functional connectivity to overcome structural connectivity limitations and identifies connections between distinct brain regions. The PLV-CNNM achieves an overall accuracy of 75.10% across the 1-51 Hz frequency range. In the preferred 8-30 Hz frequency band, known for motor imagery data classification (including α, µ, and ß waves), individual accuracies of 91.9%, 90.2%, and 85.8% are attained for α, µ, and ß, respectively. Moreover, the model performs admirably with 84.3% accuracy when considering the entire 8-30 Hz band. Notably, the PLV-CNNM reveals robust connections between different brain regions during motor imagery tasks, including the frontal and central cortex and the central and parietal cortex. These findings provide valuable insights into brain connectivity patterns, enriching the comprehension of brain function. Additionally, the study offers a comprehensive comparative analysis of diverse brain connectivity modeling methods.

Primary Central Nervous System Burkitt Lymphoma, Presenting with Long-Term Fluctuating Level of Consciousness: A Case Report and Literature Review on Challenges in Diagnosis and Management.

BACKGROUND Burkitt lymphoma (BL) is an aggressive subtype of B-cell non-Hodgkin lymphoma (NHL) rarely affecting the central nervous system (CNS) as a primary disease. Over the past years, only a few cases of primary CNS Burkitt lymphoma were reported. There is a challenge in early recognition and diagnosis of this type of brain lymphoma. Furthermore, there is no specific treatment protocols for primary CNS Burkitt lymphoma, which adds to the difficulty in managing those patients. We introduce a case of a 65-year-old who presented with fluctuating memory disturbance diagnosed as cerebral Burkitt lymphoma. CASE REPORT A 65-year-old man developed a gradual decrease in his level of consciousness over a span of 4 days, associated with fluctuating memory disturbances. A CT scan showed a hyperdense mass in the region of the trigon of the left lateral ventricle and marked obstructive hydrocephalus involving the temporal, occipital horns, and the left lateral ventricle, with no evidence of other suspicious lesions. A brain biopsy of the lesion revealed features of encephalitis initially, but the patient presented later with worsening symptoms, and a repeated brain biopsy showed features of Burkett lymphoma, with normal pan-CT scan. CONCLUSIONS Primary CNS Burkitt lymphoma (PCNSBL) is a rare disease with no clear evidence in the literature of how to deal with it. Reporting such cases provides a better understanding of how to approach such unusual presentations. Treatment of PCNSBL is challenging and even with the currently adopted approaches, the disease still has a very poor outcome.

Immunogenicity of The BNT162b2 COVID-19 mRNA and ChAdOx1 nCoV-19 Vaccines in Patients with Hemoglobinopathies.

INTRODUCTION: Studies assessing immune responses following Pfizer-BioNTech BNT162b2 mRNA COVID-19 (Pfizer) and ChAdOx1 nCoV-19 AZD1222 (AstraZeneca) vaccines in patients with hemoglobinopathy are non-existent in the literature despite being thought at high risk of infection. METHODS: Prospectively, we collected serum from patients with hemoglobinopathies at least 14 days post vaccine and measured neutralizing antibodies (nAb) in addition to binding antibodies using in-house assays. RESULTS: All 66 participants mounted a significant binding antibody response (100%), but nAbs were detected in (56/66) post-vaccine with a rate of 84.5%. Age, gender, vaccine type, spleen status, hydroxyurea use, and hyperferritinemia did not affect the rate significantly. While 23/32 (71.8%) patients receiving only one dose of the vaccine were able to mount a positive response, 33/34 (97.05%) of those who had two doses of any vaccine type had a significant nAbs response. Patients who had anti-nucleocapsid (N), signifying asymptomatic infection in the past, were able to produce nAbs (31/31). No nAbs were detected in 10/35 (28.5%) patients with no anti-N antibodies. CONCLUSION: Our results provide supportive data when advising patients with hemoglobinopathy to receive COVID-19 vaccines and ensure booster doses are available for better immunity. Whenever available, measurement of nAb is recommended.

COVID-19 Vaccine Perception and Hesitancy Among Patients With Sickle Cell Disease in the Western Region of Saudi Arabia.

BACKGROUND:  In the era of the coronavirus disease-2019 (COVID-19) pandemic, the race toward shielding the public through vaccination is still going. Patients with sickle cell disease (SCD) require special consideration given their medical needs and the common side effects of immunization, affecting their decision. Therefore, we aimed to assess the perception and hesitancy toward COVID-19 vaccination in this population and explore the possible factors when it comes to vaccination decisions. METHODS:  The present cross-sectional phone interview study was conducted between May 10 and 20, 2021. The questionnaire was administered by the medical staff. The participants were all patients with SCD presented to King Abdulaziz University Hospital in Jeddah, Saudi Arabia.  Results: Out of 346 patients, 147 patients agreed to participate. Only 52 (35.37%) patients received at least one dose of the nationally available vaccines, and there were no reported serious side effects. Among the unvaccinated participants, 45 patients (47.8%) were undecided. The most reported reasons for hesitancy were the fear of developing complications as their acquaintance had and the fear of developing brain blood clots post vaccination. CONCLUSIONS:  The number of vaccinated patients with SCD was unfortunately low in our study, secondary to hesitancy. This represents a significant barrier and needs to be tackled appropriately at any proper interaction with a patient with SCD. The absence of major side effects and vaso-occlusive crises is assuring.

Pattern and type of amputation and mortality rate associated with diabetic foot in Jeddah, Saudi Arabia: A retrospective Cohort Study.

BACKGROUND: Diabetic foot complications constitute a major public health problem worldwide, especially in Jeddah, Saudi Arabia, where the prevalence of diabetes is high. Our study was designed to determine the pattern and type of amputations performed on patients with diabetic foot admitted to a tertiary center in Jeddah, Saudi Arabia; we also aimed to determine the 7-year mortality rate of patients with diabetic foot at the same institution. MATERIALS AND METHODS: This retrospective study was conducted between January 2013 and September 2020 at a tertiary center in Jeddah, Saudi Arabia. It included all patients previously diagnosed with diabetes mellitus who presented to the hospital with either diabetic foot ulcers or foot gangrene (dry/wet/gas). The medical records of 358 patients were reviewed to acquire information regarding demographics, admission history regarding diabetes and its outcome, medical and surgical history, the level of amputation, and the presence of infection. RESULTS: Among the participants, 84.9% underwent amputation, 38.2% underwent minor amputations, 40.1% underwent major amputations, and 21.7% underwent both types of amputation. The most common cause of amputation was infection (50.3%). There were 75 deaths and a 7-year mortality rate of 20%. Low mean hemoglobin and high mean creatinine levels were significantly associated with mortality (p < 0.05). CONCLUSION: Efforts to decrease the risk of amputation and mortality among patients with diabetic foot complications are required. Early detection of the risk factors and intervention in specialist centers with a multidisciplinary approach is essential.

Low clinical utility of testing for anti-platelet factor 4 in asymptomatic individuals after ChAdOx1 nCoV-19 vaccine.

INTRODUCTION: The development of anti-platelet factor 4 (PF4) antibodies is linked to a rare thrombotic complication described now as vaccine-induced immune thrombotic thrombocytopenia (VITT). This clinical syndrome with thrombosis and thrombocytopenia was reported after exposure to the Oxford-AstraZeneca COVID-19 vaccine, ChAdOx1 nCoV-19 vaccine (AZD1222), and Ad26.COV2.S vaccine (Janssen/Johnson & Johnson). In the absence of the clinical features, the incidence of positive anti-PF4 antibodies in asymptomatic individuals post-vaccination is unclear. METHODS: The aim of this study was to evaluate the development of anti-PF4 antibodies in asymptomatic individuals 14-21 days after receiving the first dose of ChAdOx1 nCoV-19 vaccine (AZD1222) and BNT162b2 vaccine. Prospectively, we collected serum from individuals before and after ChAdOx1 nCoV-19 vaccine and BNT162b2 vaccine and measured anti-PF4 antibodies using the Asserachrom HPIA IgG ELISA (Stago, Asnieres, France). RESULTS: We detected positive anti-PF4 antibodies in 5 of 94 asymptomatic individuals post-vaccine with a rate of 5.3% with low titers (OD 0.3-0.7). Four of 5 individuals who tested positive after the vaccine had also positive anti-PF4 antibodies before the vaccine, which indicates that a majority of the positive results are due to preexisting anti-PF4 antibodies. We did not find a relation between the development of anti-PF4 antibodies and the immune response to the vaccine, status of prior COVID-19 infection, and baseline characteristics of participants. None of the participants developed thrombosis nor thrombocytopenia. CONCLUSION: Our results provide new evidence to guide the diagnostic algorithm of suspected cases of VITT. In the absence of thrombosis and thrombocytopenia, there is a low utility of testing for anti-PF4 antibodies.

Anterior Cruciate Ligament Injury in Association With Other Knee Injuries in King Abdulaziz University Hospital, Saudi Arabia.

Purpose The purpose of this study was to study the association of anterior cruciate ligament (ACL) injury with meniscal, collateral ligament, and bone injuries using magnetic resonance imaging (MRI) for clinical correlation during ACL repair. Methods This was a retrospective cohort study conducted on 136 patients diagnosed with ACL injury by MRI at King Abdulaziz University Hospital (KAUH) between September 2010 and September 2018. Results The medial meniscus was injured in approximately half (49.3%) of patients, while the lateral meniscus was injured in 16.2%. Regarding collateral ligament injuries, the medial collateral ligament was injured in six patients (4.4%), the lateral collateral ligament in four patients (2.9%), and both collateral ligaments in three patients (2.2%). There was a significant relationship between the age group and the side of ACL injury (P<0.05) but not between the age group and the presence of an associated injury. Conclusion There was no significant relationship between ACL injury and menisci, collateral ligament, or bone injury.

Epistaxis and gross haematuria with severe thrombocytopaenia associated with influenza vaccination.

Epistaxis may be attributed to many causes during the winter including dry mucous membranes from low indoor humidity from heating. However, epistaxis may also be due to thrombocytopaenia. Immune thrombocytopaenia purpura (ITP) is an autoimmune disorder causing thrombocytopaenia. Viral infections sometimes lead to ITP. Vaccines, predominantly the measles-mumps-rubella vaccine, have been associated with the development of ITP. There are several published case reports regarding influenza vaccine induced ITP. However, an association between ITP and influenza vaccination has not been firmly proven yet. We report the case of an adult with three episodes of epistaxis, each within 1 week of receiving a yearly influenza trivalent inactivated vaccine, the last episode being more severe and also featuring gross haematuria.

Empyema due to severe Pasteurella multocida treated with quinolone: a case report.

Pasteurella multocida (PM) is gram-negative coccobacillus that is commonly acquired through a cat scratch or bite. The standard antibiotic of choice for treating PM is penicillin. We present a case of PM empyema in a penicillin allergic 56-year-old female who has a history of contact with domestic cats and is known to have chronic obstructive pulmonary disease and a chronic history of smoking. The patient was treated successfully with Levofloxacin as alternative treatment to penicillin.