Recurrent Levamisole-Induced Agranulocytosis Complicated by Bowel Ischemia in a Cocaine User.

BACKGROUND Levamisole is a common adulterant of cocaine and up to 69% of seized cocaine in United States contains levamisole. It is a synthetic imidazothiazole derivative which was previously used as an immunomodulating agent for treatment of various connective tissue disorders and colorectal carcinoma. However, it was withdrawn later from the market due to significant toxicity associated with it. CASE REPORT We present the case of a 59-year-old male patient with a history of active cocaine use who presented to the hospital with febrile neutropenia and agranulocytosis. He underwent extensive work-up for neutropenia and was suspected to have it secondary to levamisole-adulterated cocaine. He was treated with antibiotics and granulocyte-stimulating factor. His white cell count improved and he was discharged home. He continued to use cocaine after discharge from the hospital. He returned to the hospital 3 weeks later with recurrent neutropenia and agranulocytosis complicated by septic shock and bowel necrosis which required prolonged antibiotics and a bowel resection. CONCLUSIONS Levamisole-induced agranulocytosis should be considered in patients who present with neutropenia and a history of cocaine use. Physicians should have high clinical suspicion and consider it a potential etiology of agranulocytosis when other causes have been excluded.

RNAseq analysis of bronchial epithelial cells to identify COPD-associated genes and SNPs.

BACKGROUND: There is a need for more powerful methods to identify low-effect SNPs that contribute to hereditary COPD pathogenesis. We hypothesized that SNPs contributing to COPD risk through cis-regulatory effects are enriched in genes comprised by bronchial epithelial cell (BEC) expression patterns associated with COPD. METHODS: To test this hypothesis, normal BEC specimens were obtained by bronchoscopy from 60 subjects: 30 subjects with COPD defined by spirometry (FEV1/FVC < 0.7, FEV1% < 80%), and 30 non-COPD controls. Targeted next generation sequencing was used to measure total and allele-specific expression of 35 genes in genome maintenance (GM) genes pathways linked to COPD pathogenesis, including seven TP53 and CEBP transcription factor family members. Shrinkage linear discriminant analysis (SLDA) was used to identify COPD-classification models. COPD GWAS were queried for putative cis-regulatory SNPs in the targeted genes. RESULTS: On a network basis, TP53 and CEBP transcription factor pathway gene pair network connections, including key DNA repair gene ERCC5, were significantly different in COPD subjects (e.g., Wilcoxon rank sum test for closeness, p-value = 5.0E-11). ERCC5 SNP rs4150275 association with chronic bronchitis was identified in a set of Lung Health Study (LHS) COPD GWAS SNPs restricted to those in putative regulatory regions within the targeted genes, and this association was validated in the COPDgene non-hispanic white (NHW) GWAS. ERCC5 SNP rs4150275 is linked (D' = 1) to ERCC5 SNP rs17655 which displayed differential allelic expression (DAE) in BEC and is an expression quantitative trait locus (eQTL) in lung tissue (p = 3.2E-7). SNPs in linkage (D' = 1) with rs17655 were predicted to alter miRNA binding (rs873601). A classifier model that comprised gene features CAT, CEBPG, GPX1, KEAP1, TP73, and XPA had pooled 10-fold cross-validation receiver operator characteristic area under the curve of 75.4% (95% CI: 66.3%-89.3%). The prevalence of DAE was higher than expected (p = 0.0023) in the classifier genes. CONCLUSIONS: GM genes comprised by COPD-associated BEC expression patterns were enriched for SNPs with cis-regulatory function, including a putative cis-rSNP in ERCC5 that was associated with COPD risk. These findings support additional total and allele-specific expression analysis of gene pathways with high prior likelihood for involvement in COPD pathogenesis.

Long Esophageal Stricture in a Brittle Diabetic.

AIM: We report a case of atypical esophageal stricture in a young diabetic woman. BACKGROUND: Diabetes mellitus and gastroesophageal reflux disease (GERD) are two common disorders in modern society. CASE REPORT: A young diabetic woman developed a 6-cm-long esophageal stricture. This stricture was refractory to multiple esophageal dilation procedures. She underwent subtotal esophagectomy and had excellent treatment outcome. CONCLUSION: Gastroesophageal reflux disease can cause severe long esophageal stricture in a brittle diabetic. CLINICAL SIGNIFICANCE: Improving the awareness of their association between diabetes and GERD would greatly benefit the day-to-day practice of medicine.How to cite this article: Pak SC, Darr U, Alastal Y, Yoon Y. Long Esophageal Stricture in a Brittle Diabetic. Euroasian J Hepato-Gastroenterol 2017;7(2):191-192.

Toxic Shock Syndrome: An Unusual Organism.

Streptococcal toxic shock syndrome is a rapidly fatal disease causing hypotension with multi organ dysfunction (MODS) early in the course of infection, which by definition is caused by Group A streptococcus (GAS). We describe a case of Toxic Shock like Syndrome (TSLS) in which the causative organism was not a GAS. A 71-year-old woman with hepatitis C and primary biliary cirrhosis had sudden onset of slurred speech and left arm and facial numbness. She had bilateral erythematous macular rash present on the flanks and legs. She was started on empiric antibiotics but her condition rapidly deteriorated 6 hours after admission. During this time, the development of multiple large reddish-pink areas of ecchymosis with bullae on her lower extremities, flanks, and groin were noted. She also developed multiorgan dysfunction (MODS) with renal dysfunction, coagulopathy and liver involvement. Patient expired before surgery could be performed and the time from presentation to the time of death was 16 hours. The blood and bullae fluid cultures grew Streptococcus dysgalactiae equisimilis. Streptococcus dysgalactiae equisimilis is a rare cause of TSLS which typically affects elderly or immunocompromised patients and only a few cases have been described in the literature. Our patient met criteria for TSLS which caused rapid shock and MODS. We review the literature of the cases describing the clinical characteristics of TSLS cause by non-GAS. Group G Streptococci is a rare but lethal cause of streptococcal toxic shock syndrome.

A Literature Review Revisiting Phenytoin-Induced Sinus Arrest.

Classically, phenytoin (PTN) infusion for the treatment of status epilepticus has been proven to be associated with cardiovascular toxicity, including dysrhythmias, hypotension, and cardiovascular collapse. Subsequently, fosphenytoin (FOS) was introduced on the market in 1997 with claims of having less cardiac toxicity. However, since then, many accounts of cardiac events have been reported undermining these claims. FOS gained popularity due to its water solubility, which allows 3 times faster infusion in comparison with PTN with less venous irritation and local toxicity. FOS is the phosphate ester prodrug of PTN and is rapidly converted to PTN independent of the dose and rate of administration. Intravenous FOS and PTN are bioequivalent. Adverse cardiac effects of both intravenous FOS and PTN have been correlated to the rate of infusion, concentration of the agent, known risk factors, or pre-existing hypersensitivity, and most cases have been identified after infusing a loading dose of these medications. This case report is unique, in that, the patient developed sinus arrest while concurrently receiving oral PTN and intravenous FOS. Clinicians should be more cognizant of the association of FOS and PTN with adverse cardiac events. Baseline electrocardiogram should be obtained on all patients prescribed FOS or PTN to identify underlying cardiac problems that may place the patient in a higher risk category. Telemetry should be performed on all patients receiving PTN in an inpatient setting.

Disequilibrium syndrome and prevention in nonhemodialysis patients.

Disequilibrium syndrome (DS) is a central nervous system disorder described in hemodialysis (HD) patients. The authors present 4 cases of elevated blood urea nitrogen (BUN); the first patient passed away from suspected DS, whereas the other 3 patients were identified as having a high risk of developing DS on the basis of their BUN. The authors tried to lower their BUN slowly and prevent rapid correction by different methods. This is the first study in which DS has been studied in patients who are not on HD, and methods are described to identify and prevent DS in such patients. They also review the existing literature on the pathogenesis of DS and highlight the importance of recognizing this syndrome in non-HD patients, while suggesting some innovative ways to prevent it.

CEBPG Exhibits Allele-Specific Expression in Human Bronchial Epithelial Cells.

Inter-individual variation in CCAAT/enhancer binding protein gamma (CEBPG) transcript expression in normal human bronchial epithelial cells (NBEC) is associated with predisposition to lung cancer. We hypothesize that this inter-individual variation is in part explained by cis-acting genetic variation in CEBPG. To test this hypothesis we measured transcript expression derived from each parental copy of CEBPG (ie, allele-specific expression; ASE). There was a significant 2.9-fold higher cell cycle-specific variation in ASE of CEBPG rs2772 A compared to C allele (P < 0.001). In 20% of NBEC samples, CEBPG rs2772 A allele was expressed on average 2.10 fold greater than rs2772 C allele. These data support the hypothesis that genetic variation in linkage disequilibrium with rs2772 influences regulation of CEBPG transcript expression through a trans-effect downstream of RNA polymerase II transcription and confirm that cis-acting genetic variation contributes to inter-individual variation in CEBPG transcript expression in NBEC, which is associated with variation in lung cancer risk.

Pattern of antioxidant and DNA repair gene expression in normal airway epithelium associated with lung cancer diagnosis.

In previous studies, we reported that key antioxidant and DNA repair genes are regulated differently in normal bronchial epithelial cells of lung cancer cases compared with non-lung cancer controls. In an effort to develop a biomarker for lung cancer risk, we evaluated the transcript expressions of 14 antioxidant, DNA repair, and transcription factor genes in normal bronchial epithelial cells (HUGO names CAT, CEBPG, E2F1, ERCC4, ERCC5, GPX1, GPX3, GSTM3, GSTP1, GSTT1, GSTZ1, MGST1, SOD1, and XRCC1). A test comprising these 14 genes accurately identified the lung cancer cases in two case-control studies. The receiver operating characteristic-area under the curve was 0.82 (95% confidence intervals, 0.68-0.91) for the first case-control set (25 lung cancer cases and 24 controls), and 0.87 (95% confidence intervals, 0.73-0.96) for the second set (18 cases and 22 controls). For each gene included in the test, the key difference between cases and controls was altered distribution of transcript expression among cancer cases compared with controls, with more lung cancer cases expressing at both extremes among all genes (Kolmorogov-Smirnov test, D = 0.0795; P = 0.041). A novel statistical approach was used to identify the lower and upper boundaries of transcript expression that optimally classifies cases and controls for each gene. Based on the data presented here, there is an increased prevalence of lung cancer diagnosis among individuals that express a threshold number of key antioxidant, DNA repair, and transcription factor genes at either very high or very low levels in the normal airway epithelium.

CEBPG transcription factor correlates with antioxidant and DNA repair genes in normal bronchial epithelial cells but not in individuals with bronchogenic carcinoma.

BACKGROUND: Cigarette smoking is the primary cause of bronchogenic carcinoma (BC), yet only 10-15% of heavy smokers develop BC and it is likely that this variation in risk is, in part, genetically determined. We previously reported a set of antioxidant genes for which transcript abundance was lower in normal bronchial epithelial cells (NBEC) of BC individuals compared to non-BC individuals. In unpublished studies of the same NBEC samples, transcript abundance values for several DNA repair genes were correlated with these antioxidant genes. From these data, we hypothesized that antioxidant and DNA repair genes are co-regulated by one or more transcription factors and that inter-individual variation in expression and/or function of one or more of these transcription factors is responsible for inter-individual variation in risk for BC. METHODS: The putative transcription factor recognition sites common to six of the antioxidant genes were identified through in silico DNA sequence analysis. The transcript abundance values of these transcription factors (n = 6) and an expanded group of antioxidant and DNA repair genes (n = 16) were measured simultaneously by quantitative PCR in NBEC of 24 non-BC and 25 BC individuals. RESULTS: CEBPG transcription factor was significantly (p < 0.01) correlated with eight of the antioxidant or DNA repair genes in non-BC individuals but not in BC individuals. In BC individuals the correlation with CEBPG was significantly (p < 0.01) lower than that of non-BC individuals for four of the genes (XRCC1, ERCC5, GSTP1, and SOD1) and the difference was nearly significant for GPX1. The only other transcription factor correlated with any of these five target genes in non-BC individuals was E2F1. E2F1 was correlated with GSTP1 among non-BC individuals, but in contrast to CEBPG, there was no significant difference in this correlation in non-BC individuals compared to BC individuals. CONCLUSION: We conclude that CEBPG is the transcription factor primarily responsible for regulating transcription of key antioxidant and DNA repair genes in non-BC individuals. Further, we conclude that the heavy smokers selected for development of BC are those who have sub-optimal regulation of antioxidant and DNA repair genes by CEBPG.

Concurrence of granular cell tumor and Mycobacterium tuberculosis.

Granular cell tumors (GCT) are rare, usually benign neoplasms of Schwann cell origin. Since discovery in 1926, fewer than 80 cases of GCT involving the lung have been reported. This report presents a 45-year-old male who presented with symptoms consistent with chronic pancreatitis associated with night sweats, weight loss, and a chronic productive cough. Chest radiography revealed a 3 x 4 cm left upper lobe lung mass with an unremarkable right lung field. Bronchoscopy revealed mixed mucosal abnormalities in the left upper lobe and a 4-mm polypoidal lesion in the right lower lobe. Bronchial washings stained positive for acid-fast bacilli. The left upper lobe lesion biopsy showed granulomatous inflammation with caseous necrosis consistent with tuberculosis. The right lower lobe lesion was a GCT without evidence of tuberculosis. This report reviews the literature regarding GCT and presents this unusual case of granular cell tumor co-occurring with active tuberculosis.

Pseudomonas sternoclavicular pyarthrosis.

Most cases of Pseudomonas pyarthrosis affecting the sternoclavicular joint have been reported in immunosuppressed intravenous drug users. We report a case of Pseudomonas pyarthrosis in a man who was otherwise immunocompetent, except for his age. A 66-year-old white man presented to the clinic with a 1-month history of right-sided shoulder and arm pain associated with swelling of the upper part of the chest in the region of the right sternoclavicular joint. The chest radiograph revealed opacity in the right superior mediastinum. Computed tomography scan of the chest confirmed a mass in the right sternoclavicular region with associated osteolysis of the clavicular head. A needle biopsy of the mass was negative for malignancy. An open biopsy specimen showed evidence of chronic inflammation without evidence of malignancy, and culture of the tissue grew Pseudomonas aeruginosa. The patient's symptoms improved after extensive incision and drainage of the affected area followed by treatment with antibiotics for 6 weeks.