Background: Evidence regarding the use of antipsychotics and associated venous thromboembolism (VTE) risk is inconclusive. Studies finding a relationship lack in-depth analysis; thus, the VTE risk among those treated with antipsychotic remains largely unknown. Objectives: The primary objective of this investigation was to compare the incidence of antipsychotic use in patients who developed a VTE versus those who did not. Methods: Data were collected via retrospective chart review from an ambulatory care clinic between January 2012 and August 2017. All active clinic patients within the study period were included unless they met the following criteria: age <18 years, pregnancy within the study period, and/or current or historical malignancy. The odds ratio (OR) of developing a VTE was determined using multivariate regression analysis controlling for age, gender, obesity, and smoking. Secondary end points were reviewed for participants who were exposed to an antipsychotic and subsequently developed a VTE within the study period. Results: A total of 7079 patients were included in the analysis, of whom 314 developed a VTE. Of these, 45 were exposed to an antipsychotic prior to VTE development. Nearly 25% of patients receiving an antipsychotic did not have a primary psychiatric diagnosis. Results suggest that antipsychotic use was significantly associated with increased risk of VTE development (OR = 1.481 [95% CI = 1.067 to 2.055]). Conclusion and Relevance: The results of this study suggest an association between antipsychotic use and VTE development. This association should be considered when prescribing antipsychotics and treating patients who develop a VTE after antipsychotic exposure.

Bleomycin is an antibiotic that is often used as a chemotherapeutic agent due to its antitumor activities against a variety of malignancies. A feared and often fatal side effect of this drug is a pulmonary injury causing inflammation that can progress to pulmonary fibrosis. Bleomycin damages lung endothelial cells by the production of free radicals that can only occur when it is bound to certain metals in the body. It forms a complex with iron and once activated by iron reduction, it destroys deoxyribonucleic acid (DNA). Therefore, it is suggested that the availability of iron in the body may play a role in the pathogenesis of bleomycin toxicity although no related cases have been documented. This is a case of a 75-year-old female with no prior history of pulmonary disease who was diagnosed with Hodgkin's lymphoma and received 12 doses of bleomycin over the course of six cycles of chemotherapy. She then presented to the hospital with respiratory failure five months after her completion of treatment. Interestingly, one month prior to presentation, she was given two intravenous iron infusions of ferumoxytol five days apart for the treatment of iron deficiency anemia. Within a week of receiving the iron, she developed dyspnea with a nonproductive cough. About a month after she developed these symptoms, she presented to the hospital and was found to be hypoxic with any activity and was subsequently placed on oxygen via nasal cannula. Her lung imaging showed new reticulonodular and patchy infiltrates bilaterally concerning for pneumonitis and her physical examination was significant for black discoloration of her fingertips and toes along with expiratory rhonchi heard throughout her lungs. During the hospitalization, her oxygen requirements increased, and the patient ended up in the intensive care unit on bilevel positive airway pressure. Her lung imaging, rapid progression, and skin findings made the clinical diagnosis of bleomycin toxicity. Out of concern that the intravenous iron may have played a role in the toxicity, iron chelation was attempted. The patient was given two doses of deferoxamine over two consecutive days and her symptoms of dyspnea along with her oxygen requirements improved. Unfortunately, these positive effects only lasted a few days and the patient continued to decline and ultimately passed away. This case raises many questions regarding iron's role in bleomycin toxicity, including if intravenous iron infusions may increase the risk of pulmonary injury from bleomycin. There are currently no guidelines or recommendations that suggest withholding iron supplementation in patients undergoing chemotherapy with bleomycin. There is also insufficient evidence to support the routine use of iron chelation in a patient that presents with bleomycin-induced lung injury. However, some studies suggest that iron chelation may play a role in preventing pulmonary toxicity. It may also lessen the severity of the toxicity or improve some of the related symptoms, thus warranting further research.

BackgroundPenicillin (PCN) allergy has been approximated to be reported in 10% of the United States population. Studies utilizing PCN skin testing have demonstrated that less than 1% of the population have a true PCN allergy. With increasing data on the negative consequences associated with a PCN allergy diagnosis, correctly identifying these patients is imperative. PCN skin testing has resulted in high rates of penicillin de-labeling; however, there are limited data evaluating the impact of a pharmacist-led PCN allergy evaluation with removal through utilization of oral challenges. The aim of this study was to utilize pharmacists to correctly identify those who are not penicillin-allergic to help decrease unnecessary use of broad-spectrum antibiotics and to optimize therapy.MethodsThis is a single-center, prospective review looking at a 10-month period of a pharmacist-led de-labeling project of patients with a PCN allergy. The electronic medical record system and decision support software were used to identify eligible patients. Adults ≥18 years of age with a PCN allergy were included. During the evaluation, pharmacists utilized a series of standardized questions which was reviewed with the infectious disease physician to classify the patient’s allergy. Based on classification a protocol was followed that either led to the patient retaining their allergy, or removal. The primary objective is to evaluate the rate of removal of penicillin allergies. Secondary objectives reviewed removal rate of patients on active antibiotics, and evaluate how many were switched to β-lactam.ResultsA total of 492 patients with PCN allergies were interviewed by a pharmacist. Pharmacist de-labeled 99/492 (20%) PCN allergies. Of those patients, 23% were removed through oral challenge and 76% through patient history. There were 175 patients on active antibiotics and 52/175 (30%) had their allergies removed. Finally, 36/52 (69%) were switched to a β-lactam.ConclusionA pharmacist-led penicillin allergy de-labeling project is beneficial in reducing PCN allergies when skin testing is unavailable in community hospitals. As seen about 1 in 5 patients were able to remove their allergy through allergy evaluation or oral challenge. Furthermore, pharmacist evaluation of the allergy not only helped remove the allergy but also resulted in the most appropriate antibiotic. Disclosures All authors: No reported disclosures.

West Nile virus (WNV) is classified as a <i>Flavivirus</i>, belonging to a Japanese encephalitis subgroup often transmitted via mosquitoes. The classic presentation of a WNV infection usually displays high fevers, myalgias, and headache which can progress to neck stiffness, stupor, and coma (Case Rep Infect Dis. 2020;2020:6501658). Our case study presented with a rare manifestation of ascending paralysis, encompassing the feared neuroinvasive disease pattern that is seldom exhibited. This case had an unusual presentation as certain manifestations experienced by our patient closely resembled that of Guillain-Barré syndrome, although others were more indicative of poliomyelitis-like syndrome. Overall, the mainstay of therapy in both conditions is supportive care, although the prognosis varies substantially depending on the underlying diagnosis.

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