Prevalence of pulmonary embolism among patients with recent onset of dyspnea on exertion. A cross-sectional study.

BACKGROUND: Exertional dyspnea is a frequently encountered complaint in clinical practice. However, the prevalence of pulmonary embolism (PE) among patients with dyspnea on exertion has not been reported. OBJECTIVE: The objective of this study was to assess the prevalence of objectively confirmed PE among consecutive patients visiting an emergency department because of recent onset of exertional dyspnea. METHODS: Patients aged ≤75 years with recent (<1 month) marked exertional dyspnea had a systematic workup for PE, irrespective of concomitant signs or symptoms of venous thromboembolism and alternative explanations for dyspnea. PE was excluded on the basis of a low pretest clinical probability and normal age-adjusted D-dimer. All other patients had computed tomography pulmonary angiography. An interim analysis after inclusion of 400 patients would stop recruitment if the 95% confidence interval (CI) of the PE prevalence had a lower limit exceeding 20%. RESULTS: The study was prematurely terminated after the inclusion of 417 patients. In 134 patients (32.1%), PE was excluded based on low clinical probability and normal D-dimer. PE was found in 134 (47.3%) of the remaining 283 patients, for an overall prevalence of 32.1% (95% CI, 27.8-36.8). PE was present in 40 of 204 (19.6%) patients without other findings suspicious for PE and in 94 of 213 patients (44.1%) with such findings. PE involved a main pulmonary artery in 37% and multiple lobes in 87% of the patients. CONCLUSION: The angiographic demonstration of PE is common in patients presenting with recent onset of marked exertional dyspnea, including 20% without other findings suggesting pulmonary embolism.

When Autoimmunity 'DRESSes up': A Case after Certolizumab Therapy.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is characterised by skin rash together with visceral organ involvement, lymphadenopathy, eosinophilia and atypical lymphocytosis. The syndrome is clinically heterogeneous, making diagnosis challenging. It has an annual incidence of 2 per 100,000 population and a mortality rate of 2-10%. We describe the first case of DRESS induced by certolizumab, a biologic disease-modifying antirheumatic drug (bioDMARD). LEARNING POINTS: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is an uncommon and under-reported syndrome.Its recognition is critical for treatment, especially in the emergency setting where most patients first present.In the case of unexplained fever, lymphadenopathy, cutaneous rash and characteristic laboratory findings (e.g., eosinophilia), after infectious causes have been ruled out, clinicians should always keep DRESS in mind and consider possible recent intake of a triggering drug.

Venous Thromboembolism in Patients With Autoimmune Disorders: Findings From the RIETE Registry.

Patients with autoimmune disorders are at an increased risk of venous thromboembolism (VTE), but this association has not been consistently evaluated. We used the RIETE (Registro Informatizado Enfermedad Trombo Embólica) database to compare the rates of VTE recurrences, major bleeding, and death during the course of anticoagulation, according to the presence or absence of autoimmune disorders. Of 71 625 patients with VTE recruited in February 2018, 1800 (2.5%) had autoimmune disorders. Median duration of anticoagulant therapy was slightly longer in patients with autoimmune disorders (median, 190 vs 182 days; P = .001). On multivariable analysis, patients with autoimmune disorders had a similar risk of VTE recurrences (hazard ratio [HR]: 0.93; 95% confidence interval [CI]: 0.68-1.27) or major bleeding (HR: 1.07; 95% CI: 0.82-1.40) and a lower risk to die (HR: 0.66; 95% CI: 0.54-0.81) than those without autoimmune disorders. Patients with giant cell arteritis had the highest rates of major bleeding (8.6 events per 100 patient-years) and the lowest rate of recurrences (zero). In other subgroups, the rates of both events were more balanced. During anticoagulation, patients with or without autoimmune disorders had similar rates of VTE recurrences or major bleeding. However, there were some differences between subgroups of patients with autoimmune disorders.

Management and outcome of major bleeding in patients receiving vitamin K antagonists for venous thromboembolism.

BACKGROUND: The optimal management of major bleeding in patients receiving vitamin K antagonists (VKA) for venous thromboembolism (VTE) is unclear. METHODS: We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to assess the management and 30-day outcomes after major bleeding in patients receiving VKA for VTE. RESULTS: From January 2013 to December 2017, 267 of 18,416 patients (1.4%) receiving long-term VKA for VTE had a major bleeding (in the gastrointestinal tract 78, intracranial 72, hematoma 50, genitourinary 20, other 47). Overall, 151 patients (57%) received blood transfusion; 110 (41%) vitamin K; 37 (14%) fresh frozen plasma; 29 (11%) pro-haemostatic agents and 20 (7.5%) a vena cava filter. During the first 30 days, 59 patients (22%) died (41 died of bleeding) and 13 (4.9%) had a thrombosis. On multivariable analysis, patients with intracranial bleeding (hazard ratio [HR]: 4.58; 95%CI: 2.40-8.72) and those with renal insufficiency at baseline (HR: 2.73; 95%CI: 1.45-5.15) had an increased mortality risk, whereas those receiving vitamin K had a lower risk (HR: 0.47; 0.24-0.92). On the other hand, patients receiving fresh frozen plasma were at increased risk for thrombotic events (HR: 4.22; 95%CI: 1.25-14.3). CONCLUSIONS: Major bleeding in VTE patients receiving VKA carries a high mortality rate. Intracranial bleeding and renal insufficiency increased the risk. Fresh frozen plasma seems to increase this risk for recurrent VTE.

Venous thromboembolism in radiation therapy cancer patients: Findings from the RIETE registry.

BACKGROUND: Cancer patients are at high risk of venous thromboembolism, particularly during cancer treatment. Conversely to chemotherapy, data on the epidemiology and clinical features of venous thromboembolism during radiation therapy are scarce. There is lack of evidence on the influence of radiation therapy (RT) on outcome in cancer patients with acute venous thromboembolism (VTE). METHODS: We used the RIETE (Registro Informatizado de Enfermedad ThromboEmbolica) database to assess the clinical characteristics and outcome of prospectively-collected consecutive patients with cancer-associated thrombosis occurred during the course of radiation therapy for cancer. Death, venous thromboembolism recurrences and major bleeding rates during long-term follow-up according to cancer site and treatment were compared RESULTS: 9284 Patients with active cancer and VTE were enrolled in RIETE: 4605 with pulmonary embolism (PE) and 4679 with deep vein thrombosis (DVT). In all, 1202 (13%) were receiving RT. This last sub-population had a higher rate of PE recurrences and a similar rate of DVT recurrences or major bleeding than those not receiving RT. Patients on RT had a higher rate of cerebral bleeding. CONCLUSIONS: In this cohort of cancer patients with VTE, a significant proportion of them received RT before VTE, the latter experienced a higher risk of cerebral bleeding.

Spontaneous multiple cervical artery dissection: two case reports and a review of the literature.

Although spontaneous cervical artery dissection (CAD) is an uncommon cause of stroke in the general population, it accounts for 10-25% of cerebrovascular events in young to middle-aged patients. Two or more vessels are involved in fewer than 15% of dissections, but multiple spontaneous CADs are likely to be underestimated owing to frequent spontaneous recanalization and the possible oligo-symptomatic presentation. An extensive review of the literature shows that in the last 30 years only 28 cases of multiple CADs have been reported, and that in half of these patients symptoms were minor and transient. We describe two cases of multiple spontaneous CADs presenting as transient ischemic attack (TIA), in which only a specific diagnostic flow-chart allowed us to recognize multiple vessel involvement and start the appropriate therapy.

Salmonella enteritidis pericarditis: case report and review of the literature.

A 65-year-old male patient with primary idiopathic dermatomyositis and on regular immunosuppressive therapy was admitted to our Department for fever and dyspnea. A diagnosis of hemorrhagic Salmonella enteritidis pericarditis was made. Treatment necessitated aggressive medical/surgical supervision. A review of the pertinent literature revealed that during the last decade Salmonella enteritidis has been identified as the most frequent agent of pericarditis caused by Salmonella species apart from Salmonella typhi. This, possibly as a consequence of the widespread contamination of poultry foods by this Salmonella species and/or owing to a possible peculiar affinity of Salmonella enteritidis to the pericardium.