COVID-19-associated thrombotic angiopathy improved after plasma exchange.

Utilization of therapeutic plasma exchange in select patients with COVID-19 microangiopathy may provide useful treatment by modulation of inflammatory cytokines and coagulation cascade to maintain homeostasis.

Clinical Determinants Differentiating the Severity of SARS-CoV-2 Infection in Cancer Patients: Hospital Care or Home Recovery.

Background: Cancer patients may carry a worse prognosis with SARS-CoV-2 infection. Most of the previous studies described the outcomes of hospitalized cancer patients. We aimed to study the clinical factors differentiating patients requiring hospital care vs. home recovery, and the trajectory of their anti-cancer treatment. Methods: This study was conducted in a community cancer center in New York City. Eligible patients were those who had cancer history and were diagnosed of SARS-CoV-2 infection between March 1 and May 30, 2020, with confirmatory SARs-CoV-2 virus test or antibody test. Four groups were constructed: (A) hospitalized and survived, (B) hospitalized requiring intubation and/or deceased, (C) non-hospitalized, asymptomatic, with suspicious CT image findings, close exposure, or positive antibody test, and (D) non-hospitalized and symptomatic. Results: One hundred and six patients were included in the analysis. Thirty-five patients (33.0%) required hospitalization and 13 (12.3%) died. Thirty (28.3%) patients were asymptomatic and 41 (38.7%) were symptomatic and recovered at home. Comparing to patients who recovered at home, hospitalized patients were composed of older patients (median age 71 vs. 63 years old, p = 0.000299), more who received negative impact treatment (62.9 vs. 32.4%, p = 0.0036) that mostly represented myelosuppressive chemotherapy (45.7 vs. 23.9%, p = 0.0275), and more patients with poorer baseline performance status (PS ≥ 2 25.7 vs. 2.8%, p = 0.0007). Hypoxemia (35% in group A vs. 73.3% in group B, p = 0.0271) at presentation was significant to predict mortality in hospitalized patients. The median cumulative hospital stay for discharged patients was 16 days (range 5-60). The median duration of persistent positivity of SARS-CoV-2 RNA was 28 days (range 10-86). About 52.9% of patients who survived hospitalization and required anti-cancer treatment reinitiated therapy. Ninety-two percent of the asymptomatic patients and 51.7% of the symptomatic patients who recovered at home continued treatment on schedule and almost all reinitiated treatment after recovery. Conclusions: Cancer patients may have a more severe status of SARS-CoV-2 infection after receiving myelosuppressive chemotherapy. Avoidance should be considered in older patients with poor performance status. More than two thirds of patients exhibit minimal to moderate symptoms, and many of them can continue or restart their anti-cancer treatment upon recovery.

Synchronous Hodgkin's lymphoma and seminoma: a rare coexistence and an important lesson.

Synchronous presentation of seminoma and lymphoma is rare but has important ramifications for the treatment of both malignancies. Without clinical vigilance, this situation may be easily missed, leading to inappropriate management. We describe a patient with synchronous seminoma and Hodgkin's lymphoma and discuss the implication on his treatment.

A rare case of factor V inhibitor in a patient on amiodarone therapy.

Factor V inhibitor is in itself a rare entity. We are reporting a case of an elderly male who presented with symptoms of bleeding and was later found to have developed factor V inhibitors. He had been on amiodarone for atrial fibrillation and developed hemorrhagic manifestations due to factor V inhibitors within a few months of initiating amiodarone therapy. Most of the cases of factor V inhibitors reported in the literature were found to be associated with exposure to bovine coagulation factors. However, in our case there was no evidence of bovine thrombin use during surgery. Furthermore, bovine thrombin-associated factor V inhibitors commonly emerge within 1-2 weeks after exposure during surgery versus several months later in our patient. There was dramatic improvement in the coagulation profile 6 weeks after discontinuation of amiodarone and institution of steroids and cyclophosphamide. We propose the consideration of amiodarone as a contributing agent in inhibitor generation even though a spontaneous development of factor V inhibitor could not be ruled out.

A case of factor V inhibitor with complete correction of the PT and aPTT upon mixing.

We read with interest Gartrell's recent report of a woman who developed a factor V inhibitor. Gartrell noted in his report that the inhibitor appeared to exhibit time dependence, as the mixing study showed slightly more prolongation of both the PT and the aPTT after 1 hr than immediately following mixing. We believe Gartrell's article may shed light on a recent intriguing case of a patient with factor V inhibitor at our institution.