A Case of Acquired Hemophilia A in a Patient with Exposure to COVID-19.

Acquired Hemophilia A (AHA) is a very rare autoimmune condition involving immune-mediated depletion of Factor VIII, resulting in spontaneous hemorrhage. Failure to recognize AHA as a possible etiology of hemorrhage can result in delayed diagnosis and treatment. The COVID-19 pandemic has given rise to several hematologic conditions and complications, with a rare manifestation being Acquired Hemophilia A (AHA). An interesting case of AHA following SARS-CoV-2 infection is described, along with the treatment approach and a brief review of several cases describing AHA in association with COVID-19.

Verapamil as a culprit of palbociclib toxicity.

A promising drug, palbociclib, received accelerated approval as a first line treatment when used with the aromatase inhibitor, letrozole, for postmenopausal women with hormone receptor positive advanced or metastatic breast cancer. We report a case of a patient who presented with febrile neutropenia, grade 3 stomatitis with lip swelling, periorbital edema, and transaminitis while on palbociclib and verapamil. Labs normalized upon discontinuation of verapamil and our patient was able to continue treatment with palbociclib and letrozole. Verapamil's inhibition of both permeability-glycoprotein (P-gp) and CYP3A4 is suspected to have led to the adverse side effects seen in our patient.

Altered methotrexate clearance in the treatment of CNS lymphoma with concurrent use of nitrofurantoin for a urinary tract infection.

Methotrexate is a widely used chemotherapy agent with a propensity for drug interactions placing the patient at risk for toxicities. There are several modes for altering methotrexate clearance including concomitant drugs leading to toxic effects on the kidneys, medications producing an acidic urine pH, and agents interfering with methotrexate transporters including the organic anion transporter and breast cancer resistance protein efflux pump. We report a case of a patient with central nervous system non-Hodgkin's lymphoma receiving high-dose methotrexate and being concomitantly treated for a urinary tract infection with nitrofurantoin. Subsequently, her initial methotrexate clearance was altered by the introduction of nitrofurantoin and returned to baseline when her nitrofurantoin was discontinued. This is the first case report describing the altered methotrexate clearance from concurrent administration of methotrexate and nitrofurantoin.

Hemophagocytic lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome of widespread inflammation due to massive amounts of cytokines released from activated macrophages. The most common trigger for HLH is infection from a virus, most commonly Epstein-Barr virus. Here we report an adult case of this rare and life-threatening syndrome.

Hepatocellular carcinoma disguised as liver abscesses.

The incidence of hepatocellular carcinoma (HCC) is growing rapidly in the United States. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis are being increasingly recognized as known risk factors for the development of HCC. However, this risk seems to be associated with their progression to cirrhosis. This case demonstrates an unusual initial presentation of HCC masquerading as liver abscesses in a previously healthy woman with nonalcoholic fatty liver disease without cirrhosis. Our patient's clinical presentation was suspicious for an infectious etiology due to her ongoing fever in the setting of possible zoonotic transmission, because she had just acquired two unvaccinated kittens. Abscess-like clinical presentation can be seen in HCC and is due to neoplasm-associated granulocytosis. Fever is due to pyrogen production by malignant tumor cells or by macrophages. Therefore, HCC can be difficult to differentiate from a hepatic abscess, and aspiration of malignant cells may be needed for an accurate diagnosis. Although the incidence of HCC in nonalcoholic fatty liver disease without cirrhosis is low or unknown, surveillance for HCC should be considered due to the higher prevalence of nonalcoholic fatty liver disease in the developed world and its potential risk for HCC.