Retinal artery occlusion as a probable idiosyncratic reaction to topical minoxidil: a case report

Background Minoxidil hair formulation is commonly used for the treatment of male or female androgenic alopecia. This over-the-counter product is considered safe, but should be used with caution. Ocular side effects following topical minoxidil use are rarely reported. In this paper, we report a rare case of inferior hemiretinal artery occlusion possibly caused by topical 5% minoxidil treatment. Case description A 21-year-old Asian Indian male presented to the retina clinic with sudden onset blurring of vision and superior visual field loss in the right eye since morning. He was diagnosed with androgenic alopecia and was on treatment with topical 5% minoxidil spray twice a day for the last 3 years. On examination, his corrected distance visual acuity was 6/6, N6 in both eyes. Anterior segment examination and intraocular pressure in both eyes and left eye fundus were within normal limits. Right eye fundus examination showed features suggestive of inferior hemiretinal artery occlusion, which were confirmed on fluorescein angiography and optical coherence tomography. A detailed systemic evaluation and investigations (blood pressure, random blood sugar, hematological and coagulation profile, serum homocysteine level, Mantoux test, chest x-ray, cardiac two-dimensional echography, thyroid function test, and immunological profile) did not detect any abnormalities. The ocular condition and its visual prognosis were explained to the patient, and he was asked to review after 4 weeks. Conclusion Though there is no definite cause–outcome relationship between topical minoxidil use and retinal artery occlusion development, this possibility should be kept in mind when observing retinal vascular occlusion cases with concurrent use of topical minoxidil.

Hyperbaric oxygen treatment for toxic epidermal necrolysis: A case report

Toxic epidermal necrolysis (TEN) is a potentially life-threatening muco-cutaneous disease, largely caused by an idiosyncratic reaction to medication or infectious disease, and is characterised by acute necrosis of the epidermis. No definitive consensus regarding the treatment of TEN has been agreed. A 60-year-old woman, diagnosed with multiple myeloma three months prior, was admitted with signs of TEN to the intensive care burns unit. She had been given ciprofloxacin to treat a urinary tract infection. She complained of malaise and pain, with maculopapular and bullous eruptions over her whole body on the third day of ciprofloxacin administration. Her supportive cares included intravenous immunoglobulins, pain control with analgesics, wound care, nutrition, and fluid support. Hyperbaric oxygen treatment (HBOT) was added on the second day of admission. The patient underwent 5 sessions of HBOT at 243.1 kPa (2.4 atmospheres absolute). Desquamation was noted to stop after the first session of HBOT and re-epithelisation commenced rapidly. The patient was discharged from the burn unit after 14 days of hospital admission. Improvement in this case was temporally related to the initiation of HBOT.

Case Report of A Rare Idiosyncratic Hepatotoxicity Induced by Valproic Acid

Valproate induced hepatotoxicity is a well-known side effect, which frequently required periodic monitoring of serum drug level. Hepatotoxicity caused by valproate typically occurs at supratherapeutic drug levels. Once in a while, an idiosyncratic reaction is elicited, liver injury might occur despite normal serum valproate level mainly in chronic users. We hereby identify an unusual case of acute idiosyncratic valproate induced hepatotoxicity. We report a case of a 65 years old male with dyslipidemia and history of seizure, on valproic acid therapy, presented with altered mental status and drowsiness. The patient’s home medications include only zenil 10 mg daily and valproate which was started one month ago. At presentation, He was awake, oriented, but lethargic. Laboratory testing reveals hepatocellular injury with elevated transaminase levels, direct hyperbilirubinemia and coagulopathy. The ammonia level was normal and valproate level was within the therapeutic range. Abdomen computed tomography with IV contrast and MRCP results were irrelevant. Idiosyncratic valproate toxicity was diagnosed after exclusion of all other possible etiologies and after a rapid clinical and laboratory improvement once the drug was discontinued. Based on the patient’s clinical context the diagnosis of valproate induced hepatotoxicity was confirmed. This case emphasizes the importance of identifying, diagnosing, and managing valproate toxicity when no alternative clarification for their symptoms. We need further attempts and more researches to improve the detection of adverse hepatic reactions and to obtain reliable information about the discovery of new biomarkers or tools for early prediction of DILI, as well as to obtain accurate information on epidemiology, drug safety, and pathogenesis in order to improve management for better survival.

Case Report of A Rare Idiosyncratic Hepatotoxicity Induced by Valproic Acid

Valproate induced hepatotoxicity is a well-known side effect, which frequently required periodic monitoring of serum drug level. Hepatotoxicity caused by valproate typically occurs at supratherapeutic drug levels. Once in a while, an idiosyncratic reaction is elicited, liver injury might occur despite normal serum valproate level mainly in chronic users. We hereby identify an unusual case of acute idiosyncratic valproate induced hepatotoxicity. We report a case of a 65 years old male with dyslipidemia and history of seizure, on valproic acid therapy, presented with altered mental status and drowsiness. The patient’s home medications include only zenil 10 mg daily and valproate which was started one month ago. At presentation, He was awake, oriented, but lethargic. Laboratory testing reveals hepatocellular injury with elevated transaminase levels, direct hyperbilirubinemia and coagulopathy. The ammonia level was normal and valproate level was within the therapeutic range. Abdomen computed tomography with IV contrast and MRCP results were irrelevant. Idiosyncratic valproate toxicity was diagnosed after exclusion of all other possible etiologies and after a rapid clinical and laboratory improvement once the drug was discontinued. Based on the patient’s clinical context the diagnosis of valproate induced hepatotoxicity was confirmed. This case emphasizes the importance of identifying, diagnosing, and managing valproate toxicity when no alternative clarification for their symptoms. We need further attempts and more researches to improve the detection of adverse hepatic reactions and to obtain reliable information about the discovery of new biomarkers or tools for early prediction of DILI, as well as to obtain accurate information on epidemiology, drug safety, and pathogenesis in order to improve management for better survival.

Neuroleptic Malignant Syndrome (NMS) on Clozapine with a Potential Atypical Interaction with Paliperidone

Neuroleptic Malignant Syndrome (NMS) associated with the use of first-generation antipsychotics is a widely known phenomenon. This idiosyncratic reaction is less significant with the use of second-generation antipsychotics, and only a few cases in the literature exist, describing this reaction with clozapine use. While being titrated on clozapine, the patient developed major and minor criteria features of NMS as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) criteria except for fever, a core symptom which created diagnostic uncertainty. Initially, clozapine was temporarily discontinued due to his deteriorating mental and physical state. A rechallenge was considered at a much lower dose, but due to a rapid increase in his creatinine kinase (CK) levels within a 12-hour timeframe, clozapine was permanently stopped. The evidence further suggests that the presentation of NMS for patients on this medication may be different to the classical presentation, and other criteria for diagnosis are suggested, which may lower the threshold for investigating NMS for patients on clozapine.

Neuroleptic Malignant Syndrome-an uncommon complication of a common drug- a case report

Neuroleptic Malignant Syndrome (NMS) is a life-threatening idiosyncratic reaction to neuroleptics and rarely to antidopaminergics. Although the incidence in India is 0.14%, it is potentially a fatal complication. NMS occurs due to a blockade in the dopamine receptor and nigrostriatal pathway. The following report is about our patient who was diagnosed with NMS. This patient was diagnosed of NMS due to a progressive rise in CPK NAC and liver enzymes, metabolic acidosis and pyrexia of unknown origin not responding to treatment. No foci for the cause of pyrexia were ascertained. However, a positive drug history of recent administration of Inj. Metaclopramide was the present treatment in the form of supportive care, by controlling rigidity, hyperthermia and preventing complications that can occur following the affliction of this condition. NMS is a potentially reversible fatal complication with a mortality rate of 30%. Indiscriminate usage of neuroleptics and antidopaminergics can inadvertently lead to patients developing this condition. This case has been reported to create awareness amongst physicians about this complication.

DRESS syndrome due to clobazam: a case report

Drug rash (or reaction) with eosinophilia and systemic symptoms (DRESS) is a potentially life-threatening hypersensitivity reaction to drugs characterized by rash, fever, lymphadenopathy, hematologic abnormalities, and involvement of internal organs. Initially coined in 1996, the term is used to refer to an idiosyncratic reaction to several drugs, the most common of which are carbamazepine, allopurinol, sulfasalazine, and phenobarbital. We report the case of DRESS related to clobazam in a 38-year-old female with a history of a complex seizure disorder.