International Journal of Medical and Pharmaceutical Case Reports

Epstein–Barr Virus-associated Lymphoma during Thiopurine and Anti-tumour Necrosis Factor Therapy: A Case Report

2026-06-23T11:19:41+00:00

Epstein–Barr virus (EBV)-associated lymphoproliferative disorders are uncommon but clinically important complications that may occur during immunosuppressive treatment for inflammatory bowel disease. Such events pose diagnostic and therapeutic challenges in clinical practice. Combination therapy with thiopurines and anti-tumour necrosis factor agents can impair immune surveillance and may favour EBV reactivation and lymphoproliferation. We report the case of a 39-year-old man with stenosing ileocolic Crohn’s disease, classified as A2L2B2 according to the Montreal classification, who developed EBV-positive diffuse large B-cell lymphoma during treatment with azathioprine and infliximab. The patient initially presented with mucohaemorrhagic diarrhoea and was subsequently diagnosed with Crohn’s disease after clinical, endoscopic, radiological and histological assessment. Combination therapy with infliximab and azathioprine was started in June 2021, after negative screening for hepatitis B, hepatitis C, human immunodeficiency virus and tuberculosis, and serology consistent with previous EBV infection. In August 2022, he was admitted with septic shock secondary to ileal perforation and underwent ileocaecal resection. Histopathological examination of the surgical specimen showed EBV-positive diffuse large B-cell lymphoma with tumour-free margins. Immunohistochemistry demonstrated CD20 and LMP1 positivity, absence of CD5 expression and a Ki-67 proliferation index of approximately 90%. Postoperative staging did not identify distant disease. The patient received four cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone, with complete metabolic response on follow-up positron emission tomography. Subsequent recurrence of Crohn’s disease was managed with ustekinumab after multidisciplinary discussion. This case emphasises the need for careful risk–benefit assessment, clinical vigilance and coordinated management when prolonged combination immunosuppression is used in patients with Crohn’s disease, especially when severe intestinal complications occur.

Intravenous Neostigmine-atropine for Refractory Post-dural Puncture Headache in Obstetric Patients: A Case Series

2026-06-20T12:49:42+00:00

Post-dural puncture headache is an important complication of neuraxial anaesthesia and may be particularly disabling in obstetric patients during the early postpartum period. Although many cases respond to conservative measures, persistent symptoms may interfere with ambulation, breastfeeding, and maternal recovery and may require an epidural blood patch. This retrospective case series describes the clinical response to intravenous neostigmine–atropine in six obstetric patients with post-dural puncture headache that persisted despite 48–72 hours of conservative management. Post-dural puncture headache was diagnosed clinically on the basis of orthostatic headache occurring within five days of neuraxial anaesthesia, after exclusion of alternative causes where clinically indicated. All patients received intravenous neostigmine 20 μg/kg with atropine 10 μg/kg, diluted in 20 mL of normal saline and administered over five minutes under haemodynamic monitoring. Pain severity was assessed using a 10-point visual analogue scale. Outcomes included change in headache severity, need for repeat dosing, requirement for epidural blood patch, recurrence before discharge, and adverse effects. The six patients were aged 26–31 years. Four developed headache after spinal anaesthesia with a 25G Quincke needle, and two after accidental dural puncture during labour epidural placement with an 18G Tuohy needle. Baseline visual analogue scale scores were 7–8 after conservative therapy. Following treatment, final scores decreased to 1–2 within 10–16 hours. Five patients required a second dose at 8 hours. No patient required epidural blood patch during the hospital stay, and no clinically significant adverse effects were observed. Intravenous neostigmine–atropine was associated with improvement in headache severity in this small series of obstetric patients with persistent post-dural puncture headache. Larger controlled studies are required to confirm efficacy, safety, optimal dosing, and durability of response.

Cerebral Venous Thrombosis Presenting as Optic Neuropathy: A Case Report

2026-06-05T10:37:14+00:00

Background: Cerebral Venous Thrombosis (CVT) is an uncommon cerebrovascular disorder with a highly variable clinical spectrum. While headache is the most prevalent symptom, acute and severe visual impairment as the dominant presenting feature is rare and constitutes a neuro-ophthalmic emergency.

Case Presentation: We report the case of a 63-year-old male with a chronic smoking history who presented with sudden-onset, progressive visual deterioration over three days, culminating in complete bilateral vision loss, accompanied by headache. An ophthalmology consultation revealed bilateral disc hyperemia. Neuroimaging, including Magnetic Resonance Imaging (MRI) and MR Venography, confirmed partial thrombosis involving the venous sinus confluence, posterior superior sagittal sinus, right transverse and sigmoid sinuses, and the right proximal internal jugular vein. The patient was managed with systemic anticoagulation and a course of high-dose corticosteroids for suspected compressive optic neuropathy. Clinical stabilization was achieved, and he was discharged on warfarin and a tapering dose of prednisolone.

Discussion: This case details an atypical manifestation of CVT. The pathophysiology of acute visual failure likely involves compressive optic neuropathy, corroborated by the ophthalmoscopic finding of bilateral disc hyperemia, and possible venous congestion of the optic nerves. Management necessitates a dual strategy: immediate anticoagulation to arrest thrombus propagation and corticosteroids to mitigate secondary optic nerve insult.

Conclusion: CVT should be considered in the differential diagnosis of acute, profound vision loss, particularly when accompanied by headache. Prompt diagnosis via MR Venography and expeditious, targeted intervention are critical to optimize neurological outcomes.

Evans Syndrome with Double-Positive Antiphospholipid Antibody Syndrome, NGS-Confirmed Cystic Fibrosis, Chronic Pancreatitis, Type-1 Diabetes Mellitus and Pulmonary Tuberculosis with Nocardiosis: A Rare Multi-System Overlap in a Young Adult Male

2026-06-15T11:54:30+00:00

Evans syndrome is an uncommon autoimmune hematological disorder characterized by the coexistence or sequential development of autoimmune hemolytic anemia and immune thrombocytopenia. Its occurrence with antiphospholipid antibody syndrome, cystic fibrosis, chronic pancreatitis, insulin-dependent diabetes mellitus, pulmonary tuberculosis, and nocardiosis creates a highly complex diagnostic and therapeutic situation. We report the case of a 33-year-old male with multiple established autoimmune, genetic, metabolic, and infectious comorbidities who presented with acute left lower limb pain and swelling for three days. Clinical examination showed erythema, tenderness, and swelling of the affected limb. Doppler ultrasonography confirmed deep vein thrombosis. Laboratory evaluation showed anemia, thrombocytopenia, and markedly raised D-dimer. The patient had a background of Evans syndrome, double-positive antiphospholipid antibody syndrome, next-generation sequencing-confirmed cystic fibrosis, chronic pancreatitis, insulin-dependent diabetes mellitus, pulmonary tuberculosis on anti-tubercular therapy, and nocardiosis. He had recently received eltrombopag for severe thrombocytopenia following a hemolytic episode. The thrombotic event was considered to be temporally associated with eltrombopag use in the presence of an underlying prothrombotic antiphospholipid antibody profile. Management included anticoagulation with enoxaparin, discontinuation of eltrombopag, continuation of anti-tubercular therapy, immunosuppressive therapy, insulin treatment, analgesia, and supportive care. During hospitalization, limb pain and swelling improved, and the platelet count increased to 0.60 lac/cu.mm by Day 10. This case highlights the importance of individualized risk assessment when using thrombopoietin receptor agonists in patients with prothrombotic autoimmune disease and emphasizes the need for coordinated multidisciplinary management in complex multisystem overlap presentations.

Maternal–fetal Safety During Electroconvulsive Therapy in Pregnancy: Anaesthetic Management of a High-risk Psychiatric Emergency

2026-06-22T09:25:30+00:00

Background: Severe depression during pregnancy with persistent suicidal ideation requires timely intervention, particularly when pharmacotherapy is ineffective. Electroconvulsive therapy (ECT) may provide rapid symptom control; however, uncertainty regarding periprocedural maternal-fetal safety and anaesthetic technique continues to influence its use. This case report describes the multidisciplinary anaesthetic management of modified ECT in a second-trimester high-risk psychiatric emergency.

Case Presentation: A 26-year-old primigravida at 27 weeks and 2 days of gestation presented with recurrent major depressive disorder, nutritional decline, treatment-refractory symptoms, and persistent suicidal ideation despite sequential pharmacotherapy. Following multidisciplinary planning by anaesthesia, psychiatry, obstetrics, and neonatology teams, six sessions of modified ECT were undertaken in an operating theatre with immediate obstetric and neonatal support available.

Anaesthetic Management: For each session, the patient was fasted, positioned with 15° left uterine displacement, and monitored using standard ASA monitoring. Aspiration prophylaxis was administered before treatment. After three minutes of preoxygenation, anaesthesia was induced with propofol 1 mg/kg, followed by succinylcholine 1 mg/kg. Low-pressure mask ventilation with 100% oxygen was used, and seizure adequacy was assessed clinically using the isolated arm technique. Fetal assessment comprised cardiotocography before and after the procedure, with intermittent fetal heart rate auscultation when feasible.

Outcomes: Mean motor seizure duration was 32.6 ± 5.4 seconds. Maternal oxygen saturation remained at or above 96%, and transient cardiovascular responses resolved spontaneously. No aspiration, airway event, arrhythmia, hypertensive crisis, prolonged seizure, uterine contraction, or fetal heart rate abnormality occurred. Suicidal ideation resolved after treatment. At 39 weeks and 3 days, the patient delivered a healthy female infant weighing 3,120 g with Apgar scores of 9 and 9 at one and five minutes.

Conclusion: Carefully planned modified ECT during pregnancy was feasible in this case when supported by multidisciplinary coordination, pregnancy-specific anaesthetic precautions, and structured obstetric surveillance.