Radium-223 dichloride (Ra-223) is an alpha-emitting radioisotope that targets osteoblastic metastasis of prostate cancer. For Ra-223, a favorable safety profile has been described. However, here we report a case of a fatal hematologic toxicity following the administration of Ra-223 observed at our hospital. An 80-year-old man with castration-resistant prostate cancer (CRPC) and multiple metastatic bone lesions was treated with Ra-223. He was complicated with systemic edema, constipation, and decline of renal function. One week later, he developed pancytopenia which deteriorated gradually, and died with severe prolonged pancytopenia and pneumonia 4 weeks after administration of Ra-223. Our report demonstrates the risk of fatal hematologic toxicity of Ra-223 even though pretreatment clinical and laboratory findings fulfill the selection criteria. Caution should be paid when prescribing Ra-223 to a patient with systemic edema, constipation, and decline of renal function.

Kawasaki disease is a rheumatologic disorder that is due to small- to medium-sized vessels necrotizing vasculitis with unknown origin. The disease affects children predominantly, but rarely occurs in adults. We report a case of 23-year-old woman from Iran who had got high grade fever, bilateral non-purulent conjunctivitis, myalgia, palms and soles exanthema, and desquamation. After 5 days of empirical antibiotic therapy without any organisms identified for source of infection, the diagnosis was established. No treatment with intravenous gammaglobulin and aspirin was administered and her echocardiogram showed normal coronary arteries. The age of our patient is an unusual aspect of the disease presentation in Iran. The diagnosis of Kawasaki in adults should be considered in patients with prolonged fever not responding to antibiotics with clinical features of Kawasaki disease.

Systemic lupus erythematosus is an autoimmune disease. Neuromyelitis optica (Devic’s disease) is an inflammatory disorder belonging to the central nervous system. The typical characterizations include severe, immune-mediated demyelination, and axonal damage which mostly involve optic nerves and spinal cord, also the brain and brainstem. Anti-aquaporin- 4 antibody has been recently described as a highly specific marker for neuromyelitis optica. Neuromyelitis optica occasionally is linked with systemic autoimmune disorders, including systemic lupus erythematosus. Here, we describe a 26-year-old young woman with systemic lupus erythematosus who had bilateral optic neuritis with no evidence of myelitis or other core clinical criteria. However, aquaporin 4 antibody with high titer was detected. The patient received high-dose prednisolone, cyclophsphamid, and rituximab; but this treatment caused no change in her visual acuity. In patients with systemic lupus erythematosus who complicated by optic neuritis (with or without myelitis), the association of neuromyelitis optica should be considered.

Knotting of an epidural catheter is a rare complication during the removal of an epidural catheter. There are many factors for knotting of an epidural catheter, such as the characteristics of the catheter itself, patient's factors [anatomy, position during insertion and removal of the catheter, and the body mass index (BMI)], the difficulty of the procedure and the distance of advancing the catheter in epidural space. During its removal, we experienced a knot of a lumbar epidural catheter which was inserted for labor pain analgesia. The knot was successfully removed. In this case, the knotting was due to long distance advancement of the catheter, which was double knotted and looped in epidural space, far from its distal tip. To prevent this complication, catheters should be left with less than 6 cm in length in the epidural space.

Bilateral extracranial internal carotid artery occlusion is a rare cause of transient ischemic attacks and stroke. In this situation, usually posterior circulation is the main source of brain blood supply. Insufficient posterior circulation with bilateral internal carotid artery is scarce, and its clinical picture in this condition is unpredictable. A 64-years-old man was admitted with recurrent transient ischemic attacks as hemiparesis (right hemiparesis except for one which left hemiparesis). Evaluations disclosed bilateral extracranial internal carotid artery occlusion accompanied with hypoplastic left vertebral artery and about 90% of stenosis in right vertebral artery as a main source of brain blood supply. This is a rare of case stenotic right vertebral artery as the only source of anterior and posterior brain blood supply, in absence of persistent neurologic sign, that has not been reported by now.

Hypereosinophilia is defined as eosinophil count more than 1500 per microliter that can be associated with tissue and organ damage, regardless of the underlying cause. There are various categories of diseases that are able to cause eosinophilia. Solid tumor-associated hypereosinophilia is an unusual manifestation in patients with cancer. Cytokines namely granulocytes macrophages stimulating factor (GM-CSF), interleukin 3 (IL- 3), and interleukin 5 (IL-5) may play an important role in the pathogenesis of eosinophilia development. Here, we describe a 70-year-old man with metastatic adenocarcinoma of the lung presenting with fever, weight loss, shortness of breath, and severe hypereosinophilia. In patients with compatible clinical findings and associated risk factor(s), it is important to consider lung adenocarcinoma as a differential diagnosis in patients with unexplained eosinophilia and lung symptoms with associated risk factors.

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