Adverse Effects

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• Unresolved chronic diarrhea: A case of ACEI-induced mesenteric angioedema Aastha Bharwad, Chelsea Wuthnow, Mahmoud Mahdi, Kyle Rowe Views: 311 PDF: 296 HTML: 40

  Angiotensin-converting enzyme inhibitors (ACEI) are frequently prescribed for cardiovascular and renal diseases. However, ACEI-induced visceral angioedema is a rare occurrence that often goes unnoticed and poses a diagnostic challenge due to its non-specific and diverse symptoms. Key diagnostic indicators on a CT scan include the ‘target’ sign, elongation of bowel loops, enlarged mesenteric vessels, mesenteric edema with or without ascites, thickened omentum, and the absence of vascular compromise or adenopathy. Discontinuation of ACEI usually results in symptom resolution within 48 hours. While this phenomenon is more commonly observed in females and African Americans, we present a case of a Caucasian male who underwent an extensive diagnostic evaluation, including exploratory surgery, before ACEI-induced angioedema was considered.

• RS3PE syndrome with subsequent PMR caused by long-term DPP-4 inhibitor use Yuichi Takahashi, Gautam Deshpande, Yoshinori Kanai, Kwang-Seok Yang, Toshio Naito Views: 563 HTML: 69 PDF: 482

  Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome has been reported in patients treated with dipeptidyl peptidase-4 inhibitors (DPP-4i). We experienced a case of RS3PE syndrome in a 73-year-old man with a history of type 2 diabetes, who developed RS3PE as a side effect of vildagliptin. Further to this, the patient developed polymyalgia rheumatica (PMR), the first such case associated with long-term DPP-4i use.

• Dasatinib-induced chylothorax beyond 5 years of treatment: is there actually any limit? Alberto Garcia-Zamalloa, Maria Begoña Basauri, Maria Goretti Urcelay, Adriana Sanz Views: 408 HTML: 62 PDF: 361

  Dasatinib is a tyrosine kinase inhibitor used for treatment of some specific types of leukaemia. The development of pleural effusion is a known adverse effect of dasatinib and chylothorax is exceptional. No case has been reported beyond 5 years of treatment and extensive search for an alternative diagnosis is currently suggested in such scenario. The underlying mechanism is not currently clear. We describe a woman on dasatinib treatment for more than 10 years who developed chylothorax. Drug withdrawal resolved the chylous pleural effusion. We were able to find 14 additional cases of dasatinib-related chylothorax reported up until now.

• Levodopa-induced pseudopheochromocytoma Joana Bernardino Cardoso, Ana Silveira, Sara Duarte, Ruth Fortes, Ahmed Botelho, Ana Simas, Rui Suzano Views: 526 HTML: 84 PDF: 443

  Pseudopheochromocytoma is a pathological condition presenting with paroxysmal hypertension with normal or moderate elevation in catecholamines and metanephrine levels, but no evidence of a tumoural cause. Imaging studies and I-123 metaiodobenzylguanidine scintigraphy are essential for exclusion of pheocromocytoma.
  We describe a case of pseudopheochromocytoma related to levodopa in a patient with paroxysmal hypertension, headache, sweating, palpitations and increased plasmatic and urinary metanephrine levels, without adrenal or extra-adrenal tumour. The beginning of the patient´s clinical symptoms coincided with the initiation of the levodopa treatment and the complete resolution of the symptoms occurred after the discontinuation of levodopa.

• Disseminated necrotic suppurative ulcers as a manifestation of cocaine abuse Álex García Tellado, Carmen Lasa Teja, María Rodríguez Vidriales, Mercedes De la Fuente Vázquez, Patricia Marín Oliván, Francisco Arnaiz Las Revillas Almajano Views: 357 HTML: 66 PDF: 345

  Introduction/Aims/Background: Pyoderma gangrenosum is an immune-mediated illness that can be caused by several affections, such as inflammatory bowel disease, rheumatoid arthritis, and drug use. We present a rare case of pyoderma gangrenosum induced by levamisole-adulterated cocaine. There have been few cases of this disease reported in the world. Levamisole is an anthelmintic drug used to adulterate cocaine to boost its effect. It also has immune-modulating effects causing, among others, vasculitis and dermatological problems.
  Materials and Methods: Clinical case of a 46-year-old man admitted to the hospital University Marqués de Valdecilla in Santander, Spain, in August 2022. We diagnosed pyoderma gangrenosum based on clinical, analytical, and histological parameters.
  Results: We report a case of pyoderma gangrenosum induced by consumption of levamisole-adulterated cocaine.
  Discussion: This patient suffered from a rare and extensive immune-mediated affection with characteristic primary lesions in the form of suppurative ulcers that responded to immunosuppressive treatment. Behind pyoderma gangrenosum there may be underlying conditions such as inflammatory bowel disease, or pyoderma gangrenosum may be secondary to identifiable causes such as cocaine use as in this patient.

• Drug-induced liver injury secondary to turmeric use Ashika Ajitkumar, Gaurav Mohan, Medha Ghose, Sivanaga Yarrarapu, Swara Afiniwala Views: 579 HTML: 815 PDF: 536

  Turmeric is a herbal medication and spice which has been used for thousands of years in traditional Eastern medicine for its flavour, colour, and purported anti-inflammatory, antioxidant, antineoplastic and antimicrobial properties. It has recently garnered interest and popularity worldwide for these reasons. While turmeric supplements are generally safe, some reports of toxicity are emerging. Compounds like piperine are added to turmeric to enhance its bioavailability, potentially contributing to its toxicity. Here, we describe a 55-year-old woman with progressive jaundice and elevated bilirubin and liver enzymes but no evidence of acute liver failure. She was treated with N-acetyl cysteine (NAC) for 24 hours and liver function tests (LFTs) were closely monitored. As a downtrend in LFTs was noted and the patient remained asymptomatic, she was discharged with close outpatient follow-up. LFTs eventually normalized 2 months after the initial presentation. Clinicians must keep this differential in mind when evaluating acute liver injury. With our case report, we question the utility of NAC in non-acetaminophen-related liver injury and encourage further studies.

• Severe hypertriglyceridemia after use of bempedoic acid Valentin Bovy, Anne-Marie Bogaert Views: 490 HTML: 103 PDF: 550

  Bempedoic is a new drug for the management of hypercholesterolemia, approved since 2020 by the EMA for use in Europe. In this case report, we describe a 65-year-old woman with sudden worsening of hypertriglyceridemia after the introduction of bempedoic acid. Triglyceride levels normalized quickly on withdrawal of the drug. With this case report, we want to reveal a possible association between bempedoic acid and the paradoxical occurrence of hypertriglyceridemia. Furthermore, we want to emphasize the limited evidence regarding the use of bempedoic acid in patients with pre-existing hypertriglyceridemia.

• Kratom-induced acute respiratory distress syndrome (ARDS) Justine Chinnappan, Diane Casini, Yasaman Navari, Nageshwari Palanisamy, Niraj Parikh, Elfateh Seedahmed Views: 1046 HTML: 863 PDF: 518

  The alkaloid derivatives of Mitragyna speciosa, commonly known as kratom, pose a threat to society due to its potential for abuse, adverse reactions and tendency to be used as self-medication for opioid withdrawal, pain and mood disorders. A number of deaths have been reported along with complications such as respiratory depression, cardiopulmonary arrest, torsade de pointes and seizures. Its various effects and potential are yet to be fully studied. We describe the case of a healthy young male who presented with progressive respiratory failure requiring mechanical ventilation. Imaging revealed multifocal lung infiltrates while extensive infectious and cardiac work-up was negative. Based on the clinical course, a diagnosis of acute respiratory distress syndrome (ARDS) caused by kratom was made. The patient showed gradual clinical improvement and was weaned off supplemental oxygen. This case highlights yet another adverse reaction to kratom and the growing threat posed by its use.

• Subacute combined degeneration of the spinal cord secondary to nitrous oxide-induced B12 deficiency Mohammed Shariff, Amr Abdallah, Abdul Salam, Samaah Fathima Views: 545 HTML: 173 PDF: 441

  A previously healthy adolescent male was admitted with paraesthesia of his arms and legs. He admitted to daily recreational nitrous oxide use for the previous 3–4 months. He was found to have severe vitamin B12 deficiency, while magnetic resonance imaging of his spine showed T2 hyperintensity within the dorsal columns. This was suggestive of subacute combined degeneration of the spinal cord. He was treated with intramuscular injections of hydroxocobalamin and showed moderate improvement 1 month post-discharge.

• A rare cause of recurrent haemolytic anaemia: carboplatin and paclitaxel-induced autoimmune haemolytic anaemia Pitchaporn Yingchoncharoen, Jerapas Thongpiya, Shrinkhala Maharjan, Mahmoud Abdelnabi , Samuel Kim, Sakditad Saowapa, Judy Lalmuanpuii Views: 567 HTML: 122 PDF: 375

  Drug-induced immune haemolytic anaemia (DIIHA) is a rare but serious complication affecting approximately 1 in 1,000,000 patients, but its incidence might be underestimated due to misdiagnosis. Several factors should be considered to ensure an accurate diagnosis, including previous medical history, comorbidities, drug history, the temporal relationship between drug exposure and symptom onset, haemolytic features, and comorbidities in suspected cases. The authors report a case of DIIHA caused by combination chemotherapy with carboplatin and paclitaxel complicated with haeme pigment- induced acute kidney injury.