Granulomatosis with Polyangiitis Presenting with Pyoderma Gangrenosum-Like Ulceration and Negative Cytoplasmic Antineutrophilic Cytoplasmic Antibodies in a Child.

Granulomatosis with polyangiitis (GPA), a vasculitis that most commonly affects small to medium-size vessels of the respiratory tract and kidneys, may also present with a wide array of skin findings. We present the case of a 12-year-old boy with pyoderma gangrenosum-like ulcerations on his lower extremity as the initial manifestation of GPA despite negative cytoplasmic antineutrophilic cytoplasmic antibodies (c-ANCAs). Although GPA is strongly associated with c-ANCA, c-ANCA may be negative on presentation. Thus clinical and pathologic clues must be relied upon when serologic confirmation is negative.

Hemodynamically Directed Two-Person Chest Compressions: A Case Report.

Cardiopulmonary resuscitation has a low success rate both in and out of the hospital setting. Return of spontaneous circulation, however, is considerably higher for intraoperative cardiac arrests. Chest compressions remain of utmost importance. Optimal chest compression depth is believed to be greater than 5 cm. However, this depth is often not achieved. We describe a case in which the adequacy of chest compressions, based on hemodynamic monitoring, was achieved with 2 persons simultaneously providing a compressive force. This hemodynamic-directed care resulted in return of spontaneous circulation on 2 separate occasions.

Thrombotic Microangiopathy Secondary to Intravenous Abuse of Opana® ER.

Opana ER (oxymorphone) is an opioid drug available throughout the United States, and intravenous abuse of the crushed oral formulation has been associated with drug-induced thrombotic microangiopathy. In this abstract, we describe two young patients who lived together and used Opana ER intravenously. Both presented with microangiopathic hemolytic anemia that mimicked thrombotic thrombocytopenic purpura (TTP). Treating this condition poses a clinical challenge, as it is difficult to distinguish it from TTP. The role for plasma exchange is not clear but can be used while awaiting the results of the ADAMTS-13 activity, but ultimately supportive care with drug discontinuation is the recommended therapy of choice. Patients should be counseled against Opana ER's intravenous use, and users should be offered drug rehabilitation therapy.