PHAR 111 LABORATORY

CASES FOR 1ST EXAM

SMC FLORES
CASE 1
KAPOSIS SARCOMA
PATIENT CASE: Immunosuppresion or iatrogenicassociated transplant-related Kaposis sarcoma
A 43-year old Greek male patient with end stage
renal failure of unknown etiology on dialysis
received a first cadaveric transplant on 4th of
August 2000 and the induction therapy was
methylprednisolone, cyclosporine, azathioprine,
basiliximab. Delayed graft function, pulmonary
edema, myocardial infarct, and fever complicated
the immediate post-transplant period. Acute
rejection not responding to methylprednisolone
pulses was diagnosed (two biopsies), and
mycophenolate mofetil was substituted for
azathioprine. On 29th of September he presented
high fever and sepsis due to Pseudomonas
aeruginosa. In the beginning of October 2000 and
Kaposis sarcoma appeared on the plantar areas
of the feet with human herpesvirus-8 in the blood
and a few days later he developed lung infection
due to Pneumocystis carinii. The kidney was
removed on 27th of October 2000 and the Kaposis
sarcoma regressed completely 14 months later.
On 30th of August 2006, he received a second
transplant from his sister with uneventful posttransplant period. His induction therapy was
methylprednisolone, enteric-coated mycophenolic
acid, cyclosporine and basiliximab. He was
converted to everolimus from cyclosporine on post
operation day 15th. Seven months later he
developed Kaposis sarcoma (biopsy proven)
again on the plantar areas of the feet.
Mycophenolic acid was discontinued, everolimus
dose was reduced and one month later there was
partial regression of the skin lesions. On May 2007 he
was admitted to the hospital because of high fever.
Bronchopneumonia was diagnosed by a CT of the
lungs. He received amikacin, ceftazidime and
clarithromycin
and
he
continued
on
methylprednisolone (6 mg/d) as the only
immunosuppressant. Ten days later he was
discharged taking methylprednisolone 6 mg/d and
everolimus 0.5 mg X 2. His Kaposis sarcoma was
regressing slowly. Human herpesvirus-8 was found in
the blood but not in the Kaposis sarcoma lesions
and valgancyclovir given the first 6 post-transplant
months was reinstituted.

Since that time he had repeated infectious

complications (bronchopneumonia, sepsis due to
Pseudomas aeruginosa, urinary infection due to
Klebsiella pneumoniae) and presented new lesions
on the feet. For this reason everolimus was
withdrawn. Imiquinod ointment was applied to the
feet without any result and the patient received 10
sessions of irradiation. He is on methylprednisolone
as the sole immunosuppressant since November
2007. Kaposis sarcoma lesions have regressed
almost completely at the end of May 2008. He is on
6 mg/d methylprednisolone and his serum
creatinine is 1.9 mg/dL.
Immunosuppresants:
Methylprednisolone, cyclosporine, azathioprine and
basiliximab, mycophenolate mofetil/ cophenolic
acid, everolimus
Antibacterials:
Amikacin, ceftazidime, and clarithromycin
Antiviral:
Valgancyclovir

CASE 2
INTEGUMENTARY SYSTEM: SEVER THERMAL BURN
INJURY
PATIENT CASE: 14-year-old girl with sever secondand third-degree burns rescued from an LPG gasleak accident.
Arlyn Reyes, a 14-year-old female, was transported
by ambulance to the emergency room after being
rescued from her burning house due to a LPG gasleak explosion at 4:30 am. Her aunt told the
investigators that Arlyn usually wakes up 4:30 am to
cook breakfast. Later investigations confirmed that
the leaking LPG tank filled the kitchen with highly
flammable gas which was ignited when Arlyn
opened the light switch in the enclosed area. By
the time the fire department team arrived, she
already suffered severe burns and excessive smoke
inhalation.
In the emergency room, Arlyn was unconscious. She
had second-degree burns over 5% of her body and
third-degree burns over 15% of her bodyboth
covering her thoracic and abdominal regions and

PHAR 111 LABORATORY

CASES FOR 1ST EXAM
SMC FLORES
her right elbow. Her vital signs were quite unstable:
blood pressure= 55/35; heart rate= 210 beats/ min.;
and respiratory rate= 40 breaths/ min. She was
quickly deteriorating from circulatory failure. Two IVs
were inserted and fluids were administered through
each. Her vital signs stabilized and she was
transported to the intensive care unit (ICU).
Arlyn regained consciousness the following
morning, surprisingly complaining of only minor pain
over her trunk. Following debridement of her burns
and application of broad-spectrum, topical
antibiotic, a plastic epidermal graft was applied
over the applied areas. Despite treatment with a
broad-spectrum antibiotic, she developed a
systemic staphylococcal infection, necessitating a
switch to a different antibiotic.
Arlyn began a long, slow recovery. Her position in
bed had to be changed every 2 hours to prevent
the formation of decubitus ulcers (i.e. bedsores).
She lost 10 pounds over the next 3 weeks, despite
nasogastric tube feeding of 5000 calories per day.
After 9 weeks, sheets of cultured epidermal cells
were grafted to her regenerating dermal layer. By
the 15th week of her hospitalization, her epidermal
graft was complete, and she was back on solid
foods, her antibiotics were discontinued, and she
was discharged from the hospital with a
rehabilitation plan for both physical and
occupational therapy at home.

7.

Describe the series of events that occur in skin

which is healing with a help of a skin-graft.
8. Why are bedridden patients at risk for
developing decubitus ulcers? Where on the
body do such ulcers most commonly occur?
9. Why did the patient lose so much weight
despite being on a very high-calorie diet?
10. How does scarring occur and what are its
effects on the skin?

CASE 3
MYASTHENIA GRAVIS
CHIEF COMPLAINT: A 30-year-old woman with
muscle weakness in the face.
HISTORY: M.G., a 30-year-old gymnastics instructor,
presents with complaints of muscle weakness in her
face that comes and goes, but has been getting
worse over the past two months. Most notably, she
complains that her jaw gets tired as she chews
and that swallowing has become difficult. She also
notes diplopia (double vision) which seems to
come on late in the evening, particularly after
reading for a few minutes. At work it has become
increasingly difficult to spot her gymnasts during
acrobatic moves because of upper arm weakness.

Her only remaining complains upon discharge were

scarring in the torso resulting to mild difficulty of
breathing and decreased mobility in the right
elbow.

Last month, as an active member of their NGO

group, she joined the ice bucket challenge for
patients with ALS. She thought that she has
myotonia congenital just like her cousin or also has
ALS when she experienced her symptoms so she
went to her doctor for a check-up.

GUIDE QUESTIONS:
1. Differentiate First, Second and Third degree
burns in terms of the extent of damage.
2. Why was Arlyn relatively pain-free when she
woke up?
3. Upon admission, why was her blood pressure so
low and heart rate so high?
4. Why was it important to immediately administer
intravenous fluids to Arlyn?
5. What is a broad-spectrum antibiotic, and why
did she need it? Is healthy skin normally
colonized by bacteria?
6. Why was skin-grafting necessary in this patient?
(Why not just let the skin heal on its own?)

On physical examination, she has notable ptosis of

both eyelids after repeated blinking exercises.
When smiling, she appears to be snarling.
Electromyographic testing revealed progressive
weakness and decreased amplitude of contraction
of the distal arm muscles upon repeated mild
shocks (5 shocks per second) of the ulnar and
median nerves. Both her symptoms and
electromyographic findings were reversed within 40
seconds
of
intravenous
administration
of
edrophonium (Tensilon), an acetylcholinesterase
inhibitor. Blood testing revealed high levels of antiacetylcholine receptor antibody in her plasma, and
a diagnosis of myasthenia gravis was made. M.G.

PHAR 111 LABORATORY

CASES FOR 1ST EXAM
SMC FLORES
was treated with pyridostigmine bromide, which is a
long-acting anticholinesterase drug, and was also
started with prednisone, which is a corticosteroid
drug.
She
also
underwent
occasional
plasmapheresis when her symptoms became
especially severe. She was given a prescription of
atropine as needed to reduce the nausea,
abdominal cramps, diarrhea, and excessive
salivation she experience as side effects of the
anticholinesterase drug. She is also taking her daily
calcium supplement (1000 mg) to prevent
osteoporosis because according to her shes at risk
being a woman and with the type of daily physical
activity that she has at her age.
GUIDE QUESTIONS:
1. What are the clinical features of osteoporosis?
2. Who are at risk for osteoporosis?
3. What are the classifications of osteoporosis?
4. How do you diagnose osteoporosis?
5. What is the treatment for osteoporosis?
6. What is the recommended daily intake of
calcium for all ages? For the patient?
7. How can you prevent osteoporosis?
8. Can men suffer from osteoporosis?
9. What is myotonia congenita?
10. What are the manifestations of myotonia
congenital?
11. What is Amyotrophic Lateral Sclerosis (ALS)?
12. Is there any treatment for ALS? What is the
prognosis?
13. What is the role of neuromuscular junction in
Myasthenia Gravis?
14. Why is M.G., experiencing difficulty in chewing
and double vision?
15. What is thymectomy and how is it helpful in
treating some MG patients?
16. Why must she undergo plasmapheresis when
her symptoms become severe?
17. Which muscle, when weakened, places the
patient at risk of respiratory failure? Explain.
Normal
level/rate:
Creatinine
level
Resting heart
rate
Resting
respiratory
rate

0.6 to 1.2 mg/dL in adult males

0.5 to 1.1 mg/dL in adult females
60 to 100 beats/minute
12 to 16 breaths/minute

Blood
pressure
Daily intake of
calcium

Below 120/80