24 y/o F with ESRD due to Henoch-Schönlein Purpura undergoes kidney transplant. The donor is her mother. Induced with ATG followed by Tacrolimus, Mycophenolate mofetil and prednisone.
Uneventful recovery with discharge creatinine of 0.7 mg/dL. TAC trough levels between 8-11 ng/ml . Discharge Hb of 12.1 g/dL. 2 months after surgery she notices mild fatigue and pallor, otherwise fairly asymptomatic.
On PE nothing stands out except for pallor. Lab only notable for Hb of 7.2 g/dL , normo, normo ,with normal WBC and platelet count. Anemia workup is extensive and turns up only remarkable for reticulocyte 0.29%, Haptoglobin of 89 mg/dL and a normal LDH. Subsequently, a bone marrow aspirate is done that reveals hypoplastic erythroid series and a few giant pronormoblast with nuclear inclusions as shown in fig below consistent with parvovirus B19 infection.
Blood B19 PCR comes back at 895000 copies. She is treated with 2 doses of IVIG 1 gr/kg/day on alternate days, transient discontinuation of MMF, with resolution of anemia.
Fortunately, no side effects of IVIG or other B19 manifestations occurred.
- Well-developed, well-nourished female in a moderate-to-significant degree of discomfort
- Found sitting in wheelchair
- Right lower extremity strength 5/5 throughout; reflex patella and Achilles 2/4
- Left lower extremity plantar flexion and dorsiflexion 5/5; quadriceps and hip flexors are markedly weaker on left 3+/5; Achilles reflex 2/4; patella reflex 1/4
- Marked paresthesia over the left anterior thigh to knee.
- Bilateral total knee arthroplasty scars noted; no warmth; full range of motion bilateral knee 0-110 flexion
- No pain with range of motion of the hip
- The patient had a CT of the lumbar spine disk space ordered by her primary care physician
- The CT revealed the patient has degenerative disk disease at L5-S1, but this does not explain her dermatomal complaint or, more importantly, her physical exam as above
- The patient believed that her knee replacement was a contraindication for MRI, which in this scenario it is not. Total joint replacement is generally completed with Titanium or Cobalt Chrome, neither of which is contraindicated for MRI imaging. Testing of these materials to 3 tesla magnets have been found to be safe.
- She was sent for an MRI of the lumbar spine
The green arrow represents a normal finding.
The blue arrow demonstrates a large foraminal herniated disk impaling the left exiting L3 nerve root (which correlates with her subjective and objective findings).
Coca-Cola says it is “closely watching” the use of CBD (Cannabidiol) as an ingredient in “wellness beverages” as a growing number of companies develop cannabis-infused drinks.
CBD is a cannabinoid that can be extracted from both marijuana and hemp varieties of cannabis. CBD doesn’t produce the high associated with marijuana, however, it is believed by many to have calming, anti-inflammatory and pain-relieving properties.
While Coca-Cola said it has “no interest in marijuana or cannabis,” they have stated: “Along with many others in the beverage industry, we are closely watching the growth of non-psychoactive CBD as an ingredient in functional wellness beverages around the world,” the company added. “The space is evolving quickly. No decisions have been made at this time.”
Coca-Cola released their statement after a report from Canada’s BNN Bloomberg reported that they were in “serious talks” with Aurora Cannabis, a medical marijuana producer and distributor, to develop drinks infused with CBD.
Following the BNN report, stocks for Aurora Cannabis spiked 17% and Coca-Cola’s shares rose slightly.
Aurora spokeswoman Heather MacGregor said her company “has expressed specific interest in the infused-beverage space and we intend to enter that market”.
CBD oil has boomed in popularity as a number of states and countries legalize the use of CBD, hemp and marijuana products. The CBD market is forecast to grow $2.1 billion by 2020 according to Hemp Business Journal.
Canadians can legally buy and consume cannabis starting October 17th. South Africa’s highest court has recently legalized the use of cannabis by adults in private places, although it remains illegal to sell, supply and use in public. The statement has been seen as a prelude to further legalization in the united states.
Coca-Cola has been diversifying their product portfolio with recent investments in sparkling water and coffee beverages. Demand for sugary sodas has declined each year over the last decade as consumers become more health conscious.
Beer giant Molson Coors announced on August 1st that they were teaming up with The Hydropothecary Corporation, a Canadian medical marijuana grower, to develop cannabis-infused non-alcoholic beverages. Although it likely that these beverages will not only contain CBD, but also THC, the cannabinoid that causes the high or buzz effect of marijuana.
Two weeks later, spirits company Constellation Brands announced a new $4 billion in investment in Canada’s Canopy Growth, a Canadian medical marijuana producer, in exchange for a 38% stake in the company.
- A 68 yo male presents with slowly progressing right anterior thigh and knee pain
- Pain never goes past the knee
- Saw primary care physician who treated with anti-inflammatory medications with minimal improvement
- Was sent for x-ray of the lumbar spine and diagnosed with degenerative disk disease
- Eventually sent for MRI of lumbar spine and referred to spine surgery for evaluation
- Difficulty putting on right shoe and sock
- Pain getting into the driver’s side of the car
- Coronary artery disease
- Nonsmoker, no drug or alcohol use
- Motor and neurological function in the lower extremities are normal for age
- Reflexes 2/4 at the patella and Achilles
- Dorsalis and posterior tibialis pulses +2; calf soft; no skin lesions
- Internal/external rotation of the left hip is normal with no pain
- Internal/external rotation of the right hip reproduces significant concordant pain and markedly diminished range of motion
- Full range of motion of the knee, no pain, no crepitus, no gross instability
- Negative Patrick’s test
- Blood pressure 190/105 in right arm and 110/65 in left arm
- Left brachial and radial pulses barely palpable
- Normal neurological examination
- Labs remarkable for high ESR (65 mm/hr)
- CT angiography of the aorta ordered
- Hemoglobin 11 g/dL
- Platelet count 95,000/mm3
- Creatinine 1.2 mg/dL
- Total bilirubin 1.1 mg/dL