Autoimmune Hemolytic Anemia Associated With Human Babesiosis.

Babesiosis is characterized by non-autoimmune hemolytic anemia as a result of invasion of red blood cells by intraerythrocytic protozoans. Upon evaluation of patients who have ongoing hemolysis despite antibiotic treatment, a new entity of autoimmune hemolytic anemia (AIHA) was recently identified in some patients with babesiosis. The data are limited to case reports and one case series. The aim of this research was to synthetize data on this topic according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database. In this review, we found that all patients who had developed AIHA were asplenic. All had Coombs test positive for IgG or both IgG and C3 indicating Warm AIHA. Some but not all required blood transfusion and plasma exchange. Majority of patients responded to steroids and had resolution of parasitemia on follow-up. We believe that this review will make the clinicians aware that babesiosis can not only cause non-immune hemolysis but also AIHA. It is important to differentiate between the two entities as antibiotics alone may not be sufficient for immune-mediated hemolysis caused by babesiosis.

Hemophagocytic Lymphohistiocytosis Secondary to Prostatic Adenocarcinoma.

Hemophagocytic lymphohistiocytosis (HLH) is caused by excessive immune activation. It can be primary in the setting of genetic defects or secondary in the setting of infection, inflammation, and malignancy. Here we present the fourth reported case of secondary HLH in association with prostatic adenocarcinoma and the diagnostic challenges of this rare, life-threatening condition. This is a 78-year-old male who presented to the hospital with fever and generalized weakness for three days and found to have splenomegaly, pancytopenia, markedly elevated transaminases, and ferritin. Bone marrow biopsy revealed hemophagocytes. He underwent an extensive evaluation to identify the etiology. Para-aortic lymph node biopsy was consistent with prostatic adenocarcinoma. The diagnosis of HLH needs a high index of suspicion because the presentation is nonspecific. HLH is a rapidly progressive and potentially fatal condition underscoring the need for a prompt evaluation if this condition is suspected.

Comparative Effectiveness Research: The Impact of Biologic Agents in Ethnic Minorities With Metastatic Colorectal Cancer.

BACKGROUND: Biologic agents have improved the outcomes of patients with metastatic colorectal cancer (mCRC). However, the clinical trials included a predominately white population (85%), with Hispanic and black patients underrepresented. Thus, the real world benefit for the latter remains unknown. Comparative effectiveness research is a tool allowing for this exploration. PATIENTS AND METHODS: The demographic and clinical characteristics of patients treated for mCRC from 2000 to 2011 were extracted from the medical records of Montefiore Medical Center. A semiparametric accelerated failure time model was used to assess the survival differences between patients receiving chemotherapy (CT) alone versus CT plus biologic agents (CBT). RESULTS: Of the 290 patients (black, 45.9%; Hispanic, 26.2%; and white, 27.9%), 53.8% received biologic agents. The median overall survival was 15.2 months in the CT-alone group and 25.6 months in CBT group (P = .004). On univariate analysis, a lower number of metastatic sites, carcinoembryonic antigen < 41 ng/mL, and more lines of CT were associated with improved overall survival. In a propensity score-based analysis of the entire cohort, CBT offered a survival benefit compared with CT alone (increased median survival, 1.44-fold; 95% confidence interval [CI], 1.11-1.86; P = .038). The results of the subgroup analysis suggested a survival benefit for white patients (2.01; 95% CI, 1.26-3.23; P = .031) but not for Hispanic (1.42; 95% CI, 0.91-2.20; P = .370) or black (1.12; 95% CI, 0.76-1.66; P = .596) patients. CONCLUSION: In the present cohort, CBT was associated with longer survival, with the effect mainly driven by the outcomes for white patients, with black patients not appearing to benefit. These data are provocative and warrant further confirmation. Efforts to increase ethnic minority patients' enrollment in clinical trials is required to prospectively define the benefit from novel therapies.

Medical Treatment in Elderly Patients with Non-Small Cell Lung Cancer.

OPINION STATEMENT: Lung cancer is the leading cause of cancer-related deaths worldwide. In the USA, ≈60 % of lung cancer cases are diagnosed in elderly patients (≥65 years of age). However, elderly patients are underrepresented in clinical studies, leading to a paucity of evidence to guide treatment decisions. Several treatment barriers exist in elderly patients, including comorbidities and poor performance status. In addition, lack of reliable geriatric assessment tools and physician reluctance to treat may contribute to undertreatment in this population. For decades, systemic chemotherapy for elderly patients with advanced non-small cell lung cancer (NSCLC) was either omitted or given as monotherapy, frequently with significant dose reductions, potentially compromising the efficacy of these therapies. Recent analyses of elderly subgroups from multiple clinical trials provide evidence for improved outcomes associated with platinum-based doublet chemotherapies vs monotherapy. Moreover, in the new era of precision medicine, molecularly targeted therapies and more recently immune-targeting therapies (anti-PD-1 and anti-PD-L1 agents) exhibit relatively milder toxicities but superior clinical outcomes in subgroups of patients compared with conventional cytotoxic chemotherapies. Further clinical trials will be needed to confirm similar safety and efficacy profiles of these therapeutic approaches in the elderly compared with their younger counterparts. In this article, we review available evidence from clinical studies and also present expert consensus on the management of NSCLC in the elderly, including treatment in the adjuvant setting and treatment of advanced disease. Screening tools, such as the Comprehensive Geriatric Assessment, that help to identify the right population of elderly patients suitable for systemic treatment are also discussed.

36-year-old female with catastrophic antiphospholipid syndrome treated with eculizumab: a case report and review of literature.

Catastrophic antiphospholipid syndrome (CAPS) is a rare but potentially life-threatening condition characterized by diffuse vascular thrombosis, leading to multiple organ failure developing over a short period of time in the presence of positive antiphospholipid antibodies (aPL). CAPS is a severe form of antiphospholipid syndrome, developing in about 1% of cases of classic antiphospholipid syndrome, manifesting as microangiopathy, affecting small vessels of multiple organs. It is acute in onset, with majority of cases developing thrombocytopenia and less frequently hemolytic anemia and disseminated intravascular coagulation. Lupus anticoagulant and anticardiolipin antibodies have been reported as predominant antibodies associated with CAPS. Treatment options often utilized in CAPS include anticoagulation, steroids, plasma exchange, cyclophosphamide therapy, and intravenous immunoglobulin therapy. Even though the reported incidence of this condition is considered to be low, the mortality rate is approaching 50%. The high rate of mortality should warrant greater awareness among clinicians for timely diagnosis and treatment of this life-threatening condition. Studies have shown that complement activation plays a key role in the pathogenesis of aPL mediated thrombosis in CAPS. We report a case of a 36-year-old female admitted with clinical and laboratory findings consistent with CAPS successfully treated with eculizumab, a terminal complement inhibitor.