A 29-year-old male patient, with no prior known medical or dermatological comorbidities or any drug allergy, was diagnosed as a case of Stage IIIB testicular cancer. Contrast-enhanced computed tomography chest, and abdomen was suggestive of the lobulated lesion in paraaortic region with multiple bilateral lung nodules, mediastinal, and hilar lymphadenopathy []. Preoperative tumor marker analysis revealed serum alpha-feto protein level 12,100 ng/ml, serum beta human chorionic gonadotropin (HCG) level 2.39 mIU/ml, and serum lactate dehydrogenase (LDH) level 819 U/L. He underwent right high inguinal orchiectomy in May 2015. Final histopathology report was suggestive of mature cyctic teratoma of right testis with associated features of intratubular germ cell neoplasia []. Postoperative tumor marker analysis revealed serum alpha-feto protein level 126 ng/ml, serum beta-HCG level 2.39 mIU/ml and serum LDH level 292 U/L. Patients pulmonary and renal function tests were normal. He was started on bleomycin (30 units on days 1, 8, and15), etoposide (100 mg/m2 on day 1–5), and cisplatin (20 mg/m2 on day 1–5) based chemotherapy (BEP chemotherapy) as per our institutional protocol. However, after 3 cycles of chemotherapy, the patient started complaining of pruritic linear rashes which patient noticed first over the trunk and then gradually increased to involved skin over the chest, back, shoulder, and bilateral upper and lower limbs []. On physical examination, linear and streaked pigmentation were seen on bilateral upper limbs, lower limbs, and over chest and back. No other skin lesions were noted. There was no mucosal involvement or systemic upset. A clinical diagnosis of bleomycin-induced flagellate rash and postinflammatory pigmentation was considered. Routine laboratory investigations, including liver and renal function tests, were normal. Bleomycin was withheld from subsequent chemotherapy cycles, and the patient was prescribed betamethasone dipropionate ointment for local application twice a day for 2 weeks. On subsequent follow ups, the itching sensation was reduced was mild hyperpigmentation remained [].
A 53-year-old man presented with unstable angina due to the severe stenosis of the left anterior descending coronary artery and obtuse marginalis, although the right coronary artery was normal. Laboratory findings, including a complete blood count, erythrocyte sedimentation rate, and C reactive protein, were normal. Chest X-ray revealed no abnormal findings, and there was no valvular abnormality on preoperative echocardiography. The patient had no co-morbid disorders, but his left ventricular ejection fraction was reduced (40–45%).\nThe intraoperative course was uneventful. There were no findings of pericarditis. On physical examination, there was no respiratory distress, blood pressure was 130/80 mm Hg, heart rate was 80 beats per minute, respiratory rate was 23 per minute, the neck veins were not distended, and there was no ankle edema. Cardiovascular system examination showed regular first and second heart sounds with no gallop or murmur. The electrocardiogram (ECG) demonstrated a Q wave in the precordial leads. For temporary coronary artery occlusion, 4/0 Viline sutures and a Bulldog Clamp were used, and warm blood was employed to de air the graft. Temporary coronary artery occlusion was not prolonged, and the electrocardiogram and hemodynamic variables and objective data showed no signs of ischemia or contractile dysfunction. The operation was uneventful. No intra-coronary shunt was utilized.\nThe patient left the operating room without any inotropic support. Six hours later, however, he developed low cardiac output. At exploration, cardiac tamponade was excluded and flowmetry showed that the graft had adequate function. There were no findings as regards pericarditis, and the patient’s postoperative erythrocyte sedimentation rate, C-reactive protein, and cardiac enzymes were normal. A high dose of adrenalin and dobutamine was administered, and an intra-aortic balloon pump was used.\nIntraoperative transesophageal echocardiography demonstrated a depression in the left ventricular function due to an akinetic lateral left ventricular wall in the region of the obtuse marginalis. After hemodynamic stabilization, the patient left the Intensive Care Unit without an intra-aortic balloon pump and inotropic support. On the fifth postoperative day, a coronary angiogram demonstrated patent grafts and correct anastomotic sites ( & ). On the seventh postoperative day, the akinetic lateral wall of the left ventricle changed to dyskinesia. Finally, after hospital discharge on the thirtieth postoperative day, an echocardiogram showed a normal left ventricular function without regional wall motion abnormalities.