A Case of Hemorrhagic Myositis Associated With Prophylactic Heparin Use in Dermatomyositis.

Dermatomyositis (DM) is a rare systemic autoimmune disease that is associated with inflammation of the skin and muscles. It typically presents with weakness of the proximal muscles along with characteristic skin lesions such as Gottron's papules and heliotrope rash. One of the most feared complications of this disease is the appearance of spontaneous hemorrhagic myositis, as most reported cases are fatal. The mechanism or risk factors of this condition have not been elucidated; however, prophylactic anticoagulation has been correlated with it in previous case reports, although idiopathic hemorrhagic myositis may also be present. We present a case of spontaneous intramuscular hemorrhage (SIH) in a recently diagnosed DM patient. A 59-year-old Hispanic male with a medical history of recently diagnosed prostate cancer and DM presented to the emergency department (ED) due to worsening anemia. His previous hemoglobin (Hgb) was 9 g/dl, but repeated laboratory tests revealed a level of 6.5 g/dl and later 5.5 g/dl at the ED. On admission, the patient was afebrile, tachycardic, and normotensive, with no overt sign of gastrointestinal bleeding. The physical exam revealed an ecchymosis on the right medial aspect of the thigh, and a digital rectal exam was negative. Computer tomography (CT) of the abdomen and pelvis without contrast was ordered due to suspicion of a retroperitoneal hematoma, revealing an interval development of a right groin complex fluid collection of up to 6 cm, concerning a possible hematoma. The patient did not have any previous vascular procedures in the area but was exposed to deep vein thrombosis (DVT) prophylaxis during the previous admission. Vascular surgery was consulted, and the recommendation was made to proceed with conservative management. On the third day, the patient developed new-onset, left-sided pleuritic chest pain. Upon examination, significant swelling and tenderness were noted in his left pectoral region, which was not present on admission. A CT chest without contrast was ordered due to concerns of underlying hematomas, revealing bilateral thickening of the pectoralis muscles, more on the right side, with a fluid collection of 2.5 cm × 1.3 cm. In addition, there was thickening of the right lateral chest wall muscles in the posterior right trapezius or supraspinatus muscles, most likely from intramuscular hemorrhage. The patient was transferred to the step-down unit for close monitoring. Conservative management was continued with as-needed transfusions for three days until hemoglobin stabilized at 9.8 mg/dL. Once stable, the patient was resumed on steroids and immunosuppressive therapy with posterior resolution of the SIH. SIH has been reported in DM, particularly more prominent in those with anti-MDA-5 antibodies. A case series and literature review showed 60.9% mortality within six months in those presenting with SIH, with a poorer prognosis (80% mortality) in those with deep muscle bleeding versus superficial (25%). There is currently no consensus on the treatment approach, and arterial embolization has not been proven effective. In our patient, conservative management with close surveillance and frequent transfusions helped achieve hemodynamic stability. Clinicians should be more aware of these rare but life-threatening complications in patients presenting with DM.

It Is Not Pneumocystis jiroveci (PCP), It Is Cyclophosphamide-Induced Pneumonitis.

Cyclophosphamide (CYC) is an immunosuppressive medication used to treat life-threatening complications of various rheumatic diseases like vasculitis and systemic lupus erythematosus. A rare side effect of this medication is pneumonitis, which occurs in less than 1% of patients. We describe a case of an 83-year-old woman with a past medical history of microscopic polyangiitis, who presented with progressive dyspnea at rest, exacerbated on exertion, and associated with orthopnea that was attributed to CYC-induced pneumonitis. Three months before this presentation, the patient was diagnosed with antineutrophil cytoplasmic antibodies (ANCA)-positive pauci-immune crescentic and necrotizing glomerulonephritis and started on CYC. On admission, a computed tomography (CT) chest showed worsening bilateral ground-glass opacities in a mosaic distribution and inter and intralobular septal thickening, not present on the CT performed three months prior. The patient underwent an extensive workup, which included an echocardiogram, bronchoscopy with bronchoalveolar lavage, and viral respiratory panel to rule out infectious and cardiac pathologies. She was started on empiric treatment with antibiotics and diuretics, however, despite these interventions, she continued with respiratory distress. A multidisciplinary team convened, and the diagnosis of CYC-induced lung injury was entertained. The CYC was discontinued, and the patient was started on prednisone with significant improvement in symptoms. This case highlights the importance of recognizing CYC as a rare cause of interstitial pneumonitis. When considering CYC-induced lung toxicity, other etiologies, such as opportunistic infections, cardiac etiologies, and diffuse alveolar hemorrhage, should be ruled out.

At the Heart of the Diagnosis: A Case of Systemic Lupus Erythematosus Presenting as Cardiac Tamponade.

Systemic lupus erythematosus (SLE) is a heterogenous, systemic disease characterized by the production of pathogenic autoantibodies against nuclear antigens. Although the most common cardiac manifestation of SLE is pericardial effusions, their progression to cardiac tamponade is rare and has an incidence between 1-3%. We describe a case of a 42-year-old Hispanic woman who presented with severe shortness of breath, vague chest pain, and hemodynamic compromise secondary to cardiac tamponade. The patient's underlying etiology of cardiac tamponade was attributed to a new diagnosis of SLE based on the 2019 European Alliance of Associations for Rheumatology/American College of Rheumatology classification (EULAR/ACR) criteria for SLE. The patient's treatment consisted of a pericardial window and immunosuppressive therapy with corticosteroids, Mycophenolate, and hydroxychloroquine. This case aims to increase awareness of SLE as a possible differential diagnosis of cardiac tamponade in the appropriate clinical setting.

Enseñanza de los cuidados paliativos en las escuelas de medicina de El Salvador / Teaching of palliative care in medical schools in El Salvador

INTRODUCCIÓN: El aumento de la prevalencia de las enfermedades crónicas no transmisibles y la complejidad del control de sus síntomas en estados avanzados ponen mucha presión a los sistemas de salud. Los cuidados paliativos son una respuesta a esta necesidad, pero el personal especializado es escaso; una opción es la enseñanza a los médicos en formación. Se pretende mostrar la situación de la enseñanza de cuidados paliativos a nivel pregrado en las escuelas de medicina de El Salvador. METODOLOGÍA: Se realizó un estudio descriptivo, observacional y transversal mediante encuestas en las que se les solicitó a representantes de las 6 escuelas de medicina en El Salvador responder preguntas sobre sus conocimientos en cuidados paliativos, importancia otorgada y presencia de la asignatura en malla curricular. RESULTADOS: El 83% respondió conocer sobre cuidados paliativos y el 100% identificó la importancia y necesidad de incluirlo dentro del plan de estudios, justificándolo por la alta prevalencia de enfermedades crónico-degenerativas. Solo una sola escuela de medicina incluye en su malla curricular la asignatura de cuidados paliativos. En 5 escuelas se imparten temas aislados en asignaturas afines. El promedio de horas totales de contenido por alumno pregrado fue de 14,1 horas. DISCUSIÓN: Aunque los entrevistados reconocieron la importancia de la enseñanza de cuidados paliativos en pregrado, el contenido total promedio de horas es bajo, mostrando una disparidad entre la enseñanza y la importancia percibida. Esto limita grandemente el desarrollo de los cuidados paliativos en el país, razón por la cual se aconseja su inclusión dentro del plan de estudios

INTRODUCTION: The increasing prevalence of chronic non-communicable diseases and the complexity of controlling their symptoms in advanced states places a lot of pressure on healthcare systems. Palliative care is a response to this need, but specialised staff are scarce, and one option is teaching doctors in training. This study attempts to present the current situation of learning palliative care at undergraduate level in the Medical Schools of El Salvador. METHODOLOGY: A descriptive, observational, and cross-sectional study was carried out using questionnaires in which representatives of the 6 medical schools in El Salvador were asked to answer questions about their knowledge in palliative care, the importance given and the presence of the subject in a curriculum grid. RESULTS: A total of 83% of those who answered knew about palliative care, and 100% identified the importance and need to include it within the curriculum. They justified this by the high prevalence of chronic-degenerative diseases. Only one medical school included the subject of palliative care in its curriculum. In 5 schools, isolated subjects are taught on related subjects. The average total hours of content per undergraduate student was 14.1 hours. DISCUSSION: Although all representatives acknowledged the importance of teaching palliative care in undergraduate courses, the average total hours content is low, showing a disparity between teaching and perceived importance. This greatly limits the development of palliative care in the country, which is why it is advisable to include it in the curriculum

Situación actual de la enseñanza de la medicina paliativa en las universidades de Centroamérica / Current status of palliative medicine training in Central American universities

INTRODUCCIÓN: En Centroamérica existe una incipiente integración de cuidados paliativos en los sistemas de salud. Organizaciones internacionales apuntan a la educación de pregrado y posgrado en medicina paliativa como una herramienta para mejorar la atención de los pacientes y las familias. En este estudio observamos la situación actual de la enseñanza universitaria de esta asignatura en la región. METODOLOGÍA: Es un estudio descriptivo, observacional, transversal. Se realizó una búsqueda de la malla curricular pregrado y posgrado de las universidades de Centroamérica disponibles virtualmente, identificando asignaturas con la denominación «medicina paliativa» para su posterior caracterización y descripción. Además, se identificaron materias afines en las cuales se podrían cubrir temas de medicina paliativa en las universidades que no cuenten con la asignatura. RESULTADOS: De las 33 universidades con malla curricular virtuales, solo en 2 (6%) se identificó la asignatura de medicina paliativa. Se identificaron 26 universidades con materias afines (78%). Se encontraron 5 cursos de posgrado de cuidados paliativos, contando solo Costa Rica con la especialidad. DISCUSIÓN: Por primera vez se dispone de una visión panorámica de lo que ocurre en las facultades de medicina respecto a la medicina paliativa. Existen muchos retos para mejorar la cobertura en cuidados paliativos en Centroamérica. Agregar a la malla curricular en pregrado la asignatura de medicina paliativa y ofrecer cursos de posgrado, pensamos que podría ayudar a acelerar la integración y dar respuesta efectiva a la demanda, como se ha visto en otros países

INTRODUCTION: Palliative care is poorly integrated into the healthcare systems of Central America. Based on this, many international organisations suggest that undergraduate education in palliative medicine is an efficient tool to improve care for patients, their families, and provide a response to the increasing demand. METHODOLOGY: A cross-sectional, observational, and descriptive study was performed by searching for undergraduate and graduate study plans from universities in Central America that were available virtually. Subjects under the name "Palliative Medicine" were identified and further characterised and described. In addition, the related materials were identified which could cover issues of palliative care at universities that do not have courses. RESULTS: Of the 33 universities with virtual study plans available online, only 2 (6%) courses of Palliative Medicine were identified. There were related subjects in 26 (78%) universities, with the most common being ethics (75%). Only 5 graduate courses of palliative medicine were found, and only Costa Rica had a specialist three-year course. DISCUSSION: This is the first time an overview has been provided on the status of palliative medicine in medical education of Central America. There are many challenges to improve coverage in palliative care in Central America. Adding the palliative medicine course to the undergraduate curriculum and offering more postgraduate studies courses can help accelerate integration and provide an effective response to demand