INTRODUCTION: Chemotherapy is the mainstay of cancer treatment. Hematological side effects are well described; however, not many dermatological complications have been reported. We present a case of fatal necrotizing fasciitis (NF) secondary to chemotherapy extravasation.CASE PRESENTATION: 55-year-old African American man with anaplastic ALK-negative large T cell lymphoma presented with fatigue, fevers, and palpitations for several weeks. Physical examination was remarkable for tachycardia and tachypnea; he required 4 liters of supplemental oxygen to saturate >90%. Laboratory workup was remarkable for WBC 18.200 m/mm3 and ESR 67 mm/h. CT scan revealed significant mediastinal lymphadenopathy. The symptoms were attributed to the malignancy and CHOP chemotherapy was started. Shortly thereafter, a painful blister at the infusion site was noted. It was deemed to be a local cutaneous vesicant effect from doxorubicin; chemotherapy was stopped and topical dimethyl sulfoxide (DMSO) was applied. No infectious process was identified but the patient continued to be febrile and tachycardic. He developed hypotension hence broadspectrum antibiotics were started. His respiratory status deteriorated and he was intubated. A new subcutaneous tissue induration near the blister rose concern for necrotizing fasciitis (NF) and he was emergently taken to the OR. The fascia was compromised and the biceps muscle was found to be necrotic. He underwent multiple surgical debridements; however, he developed septic shock and died.DISCUSSION: Necrotizing soft tissue infections are a rare but potentially fatal complication of chemotherapy. As vesicants, doxorubicin, and vincristine extravasation is known to result in tissue necrosis. Doxorubicin, an anthracycline, is associated with the highest risk for cutaneous damage. Other risk factors are immunosuppression, obesity, and previous frequent blood draws. DMSO helps with the reabsorption of chemotherapeutics. NF is characterized by rapid fascial destruction with relative skinsparing; accompanied by pain and systemic toxicity. Prompt identification is of paramount importance; however, the diagnosis is challenging as early symptoms tend to be vague. Early surgical debridement and fasciotomy improve survival; broad-spectrum antibiotic coverage and hyperbaric oxygen therapy should be started rapidly as well. Overwhelming sepsis leads to death in more than 70% of the cases.CONCLUSIONS: Chemotherapy extravasation can cause severe skin lesions and death. Initial symptoms may be mild, however, a high degree of suspicion is needed as delays in treatment are associated with poor outcomes.

Background. Thromboembolism remains a detrimental complication of COVID-19 despite the use of prophylactic doses of anticoagulation Objectives. Compare different thromboprophylaxis strategies in COVID-19 patients Methods. We conducted a systematic database search until Jun 30th, 2022. Eligible studies were randomized (RCTs) and non-randomized studies that compared prophylactic to intermediate or therapeutic doses of anticoagulation in adult patients with COVID-19, admitted to general wards or intensive care unit (ICU). Primary outcomes were mortality, thromboembolism, and bleeding events. Data is analyzed separately in RCTs and non-RCTs, and in ICU and non-ICU patients. Results. We identified 682 studies and included 53 eligible studies. Therapeutic anticoagulation showed no mortality benefit over prophylactic anticoagulation in four RCTs (OR 0.67, 95%CI, 0.18 – 2.54). Therapeutic anticoagulation didn’t improve mortality in ICU or non-ICU patients. Risk of thromboembolism was significantly lower among non-ICU patients who received enhanced (therapeutic/intermediate) anticoagulation (OR 0.21, 95%CI, 0.06 – 0.74). Two additional RCTs (Multiplatform Trial and HEP-COVID), not included in the quantitative meta-analysis, analyzed non-ICU patients and reported a similar benefit with therapeutic-dose anticoagulation. Therapeutic anticoagulation was associated with a significantly higher risk of bleeding events among non-randomized studies (OR 3.45, 95% CI, 2.32 - 5.13). Among RCTs, although patients who received therapeutic-dose anticoagulation had higher numbers of bleeding events, these differences were not statistically significant. Studies comparing prophylactic and intermediate-dose anticoagulation showed no differences in primary outcomes. Conclusions. There is a lack of mortality benefit with therapeutic-dose over prophylactic-dose anticoagulation in ICU and non-ICU COVID-19 patients. Therapeutic anticoagulation significantly decreased risk of thromboembolism risk in some of the available RCTs, especially among non-ICU patients. This potential benefit, however, may be counter-balanced by higher risk of bleeding. Individualized assessment of patient’s bleeding risk will ultimately impact the true clinical benefit of anticoagulation in each patient. Finally, we found no mortality or morbidity benefit with intermediate-dose anticoagulation.

Background: Familiar hypercholesterolemia is a genetic disorder affecting lipoprotein metabolism which is strongly associated with early atherosclerosis. Our resolve in this study is to evaluate the severity of coronary lesions ,complexity of acute interventions and clinical outcomes. Hypothesis: Patients with familiar hypercholesterolemia are relatively younger, have high coronary atheroma burden with less comorbidities, thus likely to have complex atherosclerosis but with paradoxical better prognosis. Method: A retrospective cohort study with data from the 2016 to 2018 combined National Inpatient Sample (NIS) database was employed. ICD-10 codes were used to sample all admissions for acute myocardial infarction who were then dichotomized based secondary diagnosis of familiar hypercholesterolemia. Procedure codes of ICD-10 were used to identify patients undergoing coronary revascularizations. We determined relative frequencies of various ischemic injury patterns and complexity of revascularization procedures among the two cohorts. Primary clinical outcome of mortality rate, and secondary outcomes including length of stay and total hospital charge were then assessed. Multivariate linear and logistic regressions were used to adjust for confounders. Results: We identified a total of 4,300,389 adult hospitalizations for acute myocardial infarction including 0.033% with familiar hypercholesterolemia. Patients with familiar hypercholesterolemia were younger (55.8 years vs 58.2 years, adjusted mean difference: -7.87 years, 95%CI: -9.49 years to -6.0 years). Table 1 below shows details of outcomes of our study. Conclusion: Among patients hospitalized with acute myocardial infarction, comorbid familiar hypercholesterolemia was associated with a 62% reduction in odds of in-hospital all-cause mortality despite a 2.25-fold increased odds of STEMI and higher odds for having multivessel percutaneous. revascularization.

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