Dose-adjusted EPOCH and rituximab (DA-EPOCH-R) in older patients with high-risk aggressive diffuse large B-cell lymphoma: A real-life multicenter study by the Croatian Cooperative Group for Hematologic diseases (KroHem).

PURPOSE: Dose-adjusted EPOCH and rituximab (DA-EPOCH-R) is a regimen used for the treatment of high-risk diffuse large B-cell lymphoma (DLBCL) designed to overcome resistance to standard R-CHOP by combining prolonged exposure of lymphoma cells to cytotoxic agents and dose-adjustment based on toxicity. Data on outcomes of older patients are scarce. PATIENTS AND METHODS: We collected data on patients with newly diagnosed high-risk DLBCL older than 60 years treated with DA-EPOCH-R. High-risk patients were defined by the age-adjusted international prognostic index score 2 or 3. RESULTS: A total of 120 patients were included. Median age was 69 years (range 60-82). Response rate was 74%; with 59% complete responses. Dose of DA-EPOCH-R was escalated in 50 patients (42%). Three-year progression-free survival (PFS) and overall survival (OS) was 53% and 58%, respectively, with treatment-related mortality (TRM) of 13%. In univariate analysis, favorable prognostic factors were performance status (PS) (0-2 vs. 3-4), age (<70 vs. ≥70 years), and center. In multivariate analysis, PS and center retained prognostic significance. Patients with PS 0-2 had 3-year PFS and OS of 58% and 64%, respectively, with TRM of 6%. CONCLUSION: DA-EPOCH-R is efficacious in sufficiently fit older high-risk DLBCL patients. Patients with poor PS have unacceptable toxicity and require less intensive therapy.

Lupus anticoagulant-hypoprothrombinemia syndrome with severe bleeding diathesis after coronavirus disease 2019: a case report.

Acquired antibodies against factor II (prothrombin) are rare and most commonly associated with severe liver disease or vitamin K antagonist treatment. In very rare cases, these antibodies and associated hypoprothrombinemia are found in patients with lupus anticoagulant (LAC), an antiphospholipid antibody that inhibits phospholipid-dependent coagulation tests. This uncommon entity, called lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS), may cause both severe, life-threatening bleeding and a predisposition to thrombosis. Coronavirus disease 2019 (COVID-19) is associated with a variety of coagulation abnormalities and an increased risk of thrombosis. Bleeding may occur, but it is less common than thromboembolism and has mostly been described in association with the severity of the disease and anticoagulation treatment in hospitalized patients, rarely in the post-acute phase of the disease. We report on a case of an 80-year-old man who developed LAHPS with prothrombin antibodies and severe bleeding after COVID-19.

IDIOPHATIC ASYNCHRONOUS BILATERAL SEGMENTAL TESTICULAR INFARCTION AND ANTICOAGULANT THERAPY: A CASE REPORT.

We present an unusual case of sudden onset of pain in the left testis in a patient with a previous medical history of right orchiectomy due to hemorrhagic infarction. A partial orchiectomy was performed with complete removal of the lesion and reconstruction of the testicular parenchyma. Histopathological assessment confirmed segmental testicular infarction without the presence of malignancy. The patient subsequently received anticoagulant therapy.

ASSOCIATION BETWEEN PERIODONTITIS AND LIVER DISEASE.

Recent clinical and scientific evidence confirms the negative impact of long-term periodontitis on the clinical course and progression of various liver diseases. Periodontitis is a chronic, slow-progressing infectious disease of the tooth supporting tissues caused mainly by the gram-negative bacteria Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Treponema denticola and Tannerella forsythia. These specific pathogens can be easily translocated from oral cavity to the intestine. Disruption of the intestine microbiota composition by orally derived periodontal pathogenic bacteria has recently been suggested to be a causal mechanism between periodontitis and liver disease. Furthermore, both diseases have the ability to induce an inflammatory response and lead to the creation of inflammatory mediators through which they may influence each other. Recent epidemiologic studies have demonstrated that individuals with liver cirrhosis have considerably poorer periodontal clinical parameters than those without cirrhosis. Periodontal therapy in cirrhosis patients favorably modulates oral and gut microbiome, the course of systemic inflammation, cirrhosis prognostic factors, and cognitive function. Therefore, future clinical researches should be focused on detailed examination of the biological mechanisms, strength and direction of the association between advanced liver disease and periodontitis.

SPONTANEOUS RESOLUTION OF A NONFUNCTIONING PITUITARY ADENOMA OVER ONE-MONTH PERIOD: A CASE REPORT.

Spontaneous resolution of nonfunctioning pituitary adenoma after hemorrhagic apoplexy is a rare clinical entity of unknown etiology and is defined as disappearance of a tumor without any specific treatment. Here we present a 54-year-old male patient who presented with acute onset of severe headache, vomiting, photophobia, and sonophobia. He was referred to brain computed tomography, which showed a 16x12x16 mm tumor mass located in the sellar region with signs of hemorrhage. Endocrinologic evaluation was consistent with under-function of pituitary gonadotropic cells. Magnetic resonance imaging (MRI) performed ten days later was consistent with hemorrhagic apoplexy of the pituitary adenoma. The patient's symptoms resolved after conservative treatment with dexamethasone, but he was scheduled for elective pituitary surgery. Preoperative MRI was performed one month after the first one and disclosed normal pituitary gland without any signs of adenoma. Our case is remarkable due to the fact that spontaneous remission of pituitary adenoma occurred within the first month, which is the shortest interval reported to date. Our case highlights the importance of conservative therapy as the first-line treatment for pituitary apoplexy in the absence of neurological impairment, since spontaneous remission may occur in a short time interval.

THE ASSOCIATION OF SUBCLINICAL INSULIN RESISTANCE WITH THYROID AUTOIMMUNITY IN EUTHYROID INDIVIDUALS.

Hashimoto thyroiditis is characterized by anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies that gradually lead to thyroid cell destruction. As hypothyroidism has been associated with insulin resistance (IR), we aimed to investigate whether IR is associated with thyroid antibody presence and whether the degree of IR correlates with their concentration in euthyroid individuals. A total of 164 non-diabetic, euthyroid individuals, average age 34 years, were included in the study, divided into two groups according to Hashimoto thyroiditis and underwent 5-hour oral glucose tolerance test. The degree of IR was evaluated by the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR). The Hashimoto thyroiditis group had higher HOMA-IR (p=0.003) and lower glucose levels (p=0.04). HOMA-IR correlated positively with anti-TPO (p<0.001). Linear logistic regression revealed that anti-TPO concentration increased by 18.13 (p=0.001) with each HOMA-IR unit. IR might trigger thyroid antibody production and Hashimoto thyroiditis development, which needs to be evaluated in further larger scale follow up studies.

EFFECTS OF OCCUPATIONAL STRESS ON THE ACTIVATION OF HEMOSTATIC AND INFLAMMATORY SYSTEM.

A 24-hour shift is one of the major stressors for physicians because, apart from causing fatigue and circadian rhythm disorders, it often requires making vital decisions for patients within a short time frame. It is known that workplace stress leads to the activation of the coagulation system, which can result in imbalance of the coagulation and fibrinolysis system. The state of stress can also generate proinflammatory mediators. The aim of this study was to examine the effect of 24-hour shift on global coagulation tests of D-dimers and fibrinolysis, and on C-reactive protein (CRP) as an acute inflammatory agent and proatherosclerotic factor. Sixty physicians (residents) aged 25-35 participated in this study (30 participants in the experimental group and 30 participants in the control group). In experimental group, blood samples were collected on three occasions: shortly before 24-hour shift, twelve hours after the shift had begun, and at the end of the shift. Blood samples were collected from control group participants at the same time points. The results showed that there was no statistically significant difference in the values of D-dimer and fibrinolysis between the experimental and control groups. CRP values were statistically significantly higher in the experimental (1.57, 1.49 and 1.50) than in the control group (0.79, 0.75 and 0.84) on all three measurements (p=0.024, p=0.020 and p=0.030, respectively). These results confirmed the existence of proinflammatory changes in the endothelium of blood vessels, which is a factor associated with accelerated atherosclerosis.

[Mast cell leukemia--case report]. / Mastocitna leukemija--prikaz bolesnice.

UNLABELLED: Mast cell leukemia is extremely rare, more often arises de novo and in 15% of cases developes from preexistence mast cell diseases. It is a high malignant leukemia with bad prognosis and a short survival. A 72-year old female was admitted to hospital with clinically suspected plasmocytoma. She had eccematoid changes on her trunk and underarms. Radiogramm showed osteolytic lesions of the right thigh and pelvis. FNA of the bone marrow revealed hypercellular smear with 80% of mast cells and immature mast cells which were cytochemically positive to toluidin (Figure 1. and 2.), chloracetate, alcian blue, acid fosphatase and Sudan black and negative to periodic acid Schiff (PAS) and peroxidase (POX). The peripheral blood smear showed single mast cells which were positive to toluidin. The bone marrow biopsy confirmed mast cell leukemia. The chariogramm of the bone marrow showed numerical and structural chromosomal changes. Two month after the diagnosis the patient suffered from right thigh fracture and was treated with local radiotherapy, antihistaminic and analgetic therapy. The patient died within 6 month after the diagnosis. CONCLUSION: Mast cell leukemia is very rare and high grade leukemia with short survival time. Cytological diagnosis is possible, when there is more then 20% of atypical mast cells in the bone marrow aspirate. The diagnosis of aleukemic variant of mast cell leukemia could be stated if there is less then 10% of mast cells in the peripheral blood.

Corrigendum to: Post-treatment neutrophil to lymphocyte ratio as a prognostic tool in patients treated with tocilizumab for severe COVID-19 pneumonia - a single center experience.

[This corrects the article DOI: 10.11613/BM.2023.020704.].

Efficacy and Safety of Obinutuzumab-chemotherapy Combinations in Front-line Treatment of Follicular Non-Hodgkin Lymphoma During the COVID-19 Pandemic: A Study of KROHEM, the Croatian Cooperative Group for Hematologic Diseases.

Obinutuzumab (G) has become part of front-line treatment of follicular lymphoma (FL) based on results of a large randomized study. Data on patients treated outside of clinical trials are lacking. We have retrospectively investigated efficacy and safety of G-based immunochemotherapy regimens in 114 patients treated in a real-life setting during a period of 2 years, largely coinciding with the COVID-19 pandemic. The response rate was 93.8%; 18-months overall (OS) and progression-free survival (PFS) were 88% and 84%, respectively. Patients treated with G-cyclophosphamide, vincristine and glucocorticoid + doxorubicine (CHOP) had statistically significantly superior OS and PFS compared to patients treated with G-bendamustine (G-B) (P = 0.002 and P = 0.006, respectively) due to an increase in lethal infections, most notably COVID-19, in the latter group. A total of 12 patients died during follow-up; 9 of 61 treated with G-B, 1 of 49 treated with G-CHOP and 2 of 4 treated with G-cyclophosphamide, vincristine and glucocorticoid (CVP). SARS-CoV-2 infection was diagnosed in 20 (17.5%) patients. All of the 7 treated with G-CHOP recovered, while 4 of 12 treated with G-B died. Immunoglobulin levels and severity of neutropenia were similar between the groups. In multivariate analysis, G-B in comparison to G-CHOP was an independent prognostic factor (P = 0.044, hazard ratio = 9.81) after adjustment for age, sex and Follicular Lymphoma International Prognostic Index (FLIPI). Based on our experience G has excellent antilymphoma activity in patients receiving front-line treatment for FL in real-life setting, but during the COVID-19 pandemic, it should be preferentially combined with CHOP, at least in patients younger than 65.

Psoas muscle index at the time of diagnosis might reflect the prognosis of classical Hodgkin's lymphoma patients.

We retrospectively investigated clinical and prognostic significance of psoas muscle index (PMI) calculated as total psoas muscle area at L3 vertebra level obtained from baseline computed tomography (CT) scans in 49 newly diagnosed classical Hodgkin's lymphoma (cHL) patients prior to specific treatment. Median PMI was 572.5 mm2/m2 and was significantly higher in males (P < 0.001), patients with higher body mass index (BMI, P < 0.001), absence of extranodal disease (P = 0.037), higher absolute lymphocyte count (P = 0.037), higher hemoglobin (P = 0.010) and lower lactate dehydrogenase (LDH, P = 0.050). There were no significant associations with age, disease subtype, presence of constitutional symptoms, Ann Arbor disease stage, presence of advanced disease or international prognostic score. Patients with lower PMI had significantly worse PFS (hazard ratio [HR] 4.91; P = 0.009). This phenomenon persisted in the multivariate model (HR = 5.09; P = 0.042) adjusted for International Prognostic Score (IPS) and chemotherapy type.

Position of intragastric balloons in global initiative for obesity treatment.

Obesity is chronic disease with multiple health consequences and among the most severe health problems worldwide. According to public health records around 65% of population in Croatia are overweight and 20% obese. National physicians chamber with support of Health and Social Welfare Ministry gave recommendations on diagnosing and treating of obesity in form of national consensus. Treatment of obesity is complex and enrolls multiple clinical specialties. Change of life style, strenuous physical activity and pharmacotherapy are part of conservative treatments. Patients are treated more efficiently by minimally invasive endoscopic procedures or bariatric surgery depending on starting body mass index score. Implantation of intragastric balloons is conceptually simple method of obesity treatment. Modern devices as Bio-Enterics intragastric balloons (BIB), (Inamed Health, USA) are gaining wide popularity among both patients and physicians. BIB intragastric offers the best gains with individuals ranging BMI from 35 to 40. Efficiency has relative timeline dependance from 85% at 6 months to 24% at 36 months. BIB offers substantial ameliorative influence on obesity comorbidities, particularly cardiovascular risk. Treatment with BIB is also efficient but transient treatment modality in morbidly and superobese individuals to reduce preoperative risks of general and bariatric surgery. Obesity treatment with BIB is well tolerated and safe, offering better quality of life. Nevertheless, due to relative poor results of conservative obesity treatments on long-term follow up further investigations defining new clinical parameters for solving treatment resistance. In order to provide resourcefully individualized approach modern perspectives are focused on endocrine constitutes of obesity. Hormonal effects of BIB treatment in compare to bariatric surgery are potentially interesting for the prospect studies.

Doppler ultrasound of hepatic and system hemodynamics in patients with alcoholic liver cirrhosis.

OBJECTIVE: The progression of liver cirrhosis eventually increases cardiac output, while blood pressure and systemic vascular resistance are reduced. A complex behavior of portal hemodynamic to hepatic artery and system circulation has not yet been presented. There is a lack in knowledge about the correlation of local and systemic circulation parameters to the degree of liver failure, with respect to presence of ascites and esophageal varices. PATIENTS AND METHODS: The study sample was 76 patients hospitalized for established alcoholic liver cirrhosis. Patients were divided into groups according to Child-Pugh clinical score; grade A (n = 24), B (n = 18) and C (n = 18). Ascites was found in 28 patients and esophageal varices in 46. Portal vein flow velocity (PVFV), hepatic artery resistance index (HARI), heart and great vessels within mediastinal cavity were assessed with ultrasound devices equipped with spectral Doppler. RESULTS: Significant differences in mean blood pressure, systemic vascular resistance index (SVRI) minute volume, cardiac index and PVFV were found in the group of patients with the most severe stage (C). In regard to presence of ascites statistically significant difference was observed in elevated mean blood pressure and SVRI. Correlation was found between conjugated HARI to blood pressure and to SVRI. CONCLUSIONS: In patients with liver cirrhosis there is an inversely reciprocal relationship of conjugated HARI with PVFV, correlating to disease grade. PVFV in cirrhosis decreases and HARI values were over 0.7. Study demonstrated that combining echocardiography with abdominal Doppler ultrasound served as valuable non-invasive diagnostic insight in liver and systemic circulation among different grade of cirrhosis.

Aplastic crisis induced by human parvovirus B19 as an initial presentation of hereditary spherocytosis.

The association between aplastic crisis and human parvovirus (HPV) B19 infection has been described in patients with hereditary spherocytosis (HS). Most cases of aplastic crisis in patients with HS induced by HPV B19 have been reported in children and adolescents. In this paper, we describe an aplastic crisis induced by HPV B19 in the 34 year old female as an initial presentation of HS. Although other viral illnesses cause some decompensation in HS, the anemia is rarely as profound as seen in acute HPV B19 infections.

Interference of M-protein on Thrombin Time Test: A Case Report.

OBJECTIVE: A case of interference of monoclonal protein (M-protein) on thrombin time (TT) test in a 39-year-old Caucasian male patient is presented. METHODS: Coagulation screening tests were performed where altered results only for TT result (>150 seconds) and activated partial thromboplastin time (aPTT) result (36 seconds) were measured. Further specific coagulation testing included measurement of individual coagulation factors FII, FV, FVII, FVIII, FIX, FX, FXI, and FXII. Diagnostic steps in detection and identification of monoclonal protein included serum protein electrophoresis and immunofixation (both serum and urine specimen). RESULTS: Monoclonal protein immunoglobulin G kappa detection and identification in serum and urine clarified the situation. CONCLUSION: Unexpectedly altered results of screening coagulation tests without any appropriate clinical signs and symptoms in a patient without any anticoagulant therapy needs to be critically considered in the context of extended next diagnostic steps in order to clarify the cause of pathological test results.

Quality management: patients reflections on health care at outpatient clinic of internal medicine department.

Middle and older age group relative share in the community permanently grows. Those are commonly burdened with several chronic health conditions or elevated incidence of acute ones and in more frequent need for consulting health services. In the era of modern technical medicine, it is important to increase quality of services particularly patients orientated. Department of Internal Medicine developed questionnaire to assess reflections on medical care from the receiver of medical services point of view. Sample was formed from individuals that visited outpatient triage Unit (OTU) and voluntary enrolled, during period April 1-August 31, 2008 for any medical reason. Study population structure had similarly equally of both genders, socio-economical background, and was in age range 18-87. Questionnaire was developed by team of experienced personnel covering satisfaction on received medical care. There were 279 returned formulary in a sample of 6700 patients (4.18%). Patients visited OTU chiefly on behalf medical condition secondary to address of residency, followed by personal choice, on advice given by general practitioner, by emergency transportation services, or just due to earlier experiences. Regarding provided medical care extent, 4/5 of patients were examined in lesser than 2 hours, while total workup lasted mostly for 2-4, followed by over four. Over half of patients were moderate toward highly satisfied with provided medical information, personnel communication style and general reflection on all services while being in the Department premises. Astonishing proportion of patients (93%) was satisfied with positive personnel communication. Integration of patients' self-perceived reports about medical services in organizing process is inevitable for augmenting content and at the same time valuable for developing overall quality of treatment. Communication excellence is of premier importance and unavoidable for giving additional positive effect to remain health status or to ease the healing process of individual and their families.

Influence of ATII blockers and calcium channel blockers on renal vascular resistance in patients with essential hypertension.

Doppler can evaluate renal vascular resistance, and resistance index (RI) highly correlates with blood pressure and renal function in various pathological conditions. Purpose of the study was to measure and compare renal Doppler indices in patients with newly-diagnosed essential hypertension (EH) and in healthy subjects; to determine changes of Doppler indices in patients after six-months monotherapy with either the AT II blocker (valsartane) or calcium channel blocker (niphedipine); to determine which drug has better renoprotective effect. 65 healthy controls were examined, as well as 69 patients with the newly-diagnosed EH, without signs of the target organ damage. Duplex Doppler US of interlobar intrarenal arteries was performed, and RI, acceleration index (AI) and acceleration time (AT) measured. Antihypertensive monotherapy was performed with vaslartane in 34 patients and with niphedipine in 35 patients. Doppler was repeated after the six-months therapy. RI in patients with the 1. stage of EH is significantly higher compared to the controls (p < 0.001), and significantly lower compared to the stage 2. of EH (p < 0.001). The significant decrease of systolic (p < 0.001) and dyastolic blood pressure (BP) (p < 0.001) was noted after the therapy. RI in healthy examinees (RI = 0.59 +/- 0.023) is significantly lower than in EH (RI = 0.66 +/- 0.26) (p < 0.001), while AI is significantly higher (p < 0.001), and AT is significantly lower (p < 0.001). In patients treated with valsartane and those treated with niphedipine, the RIs are significantly lower than before (p < 0.001), while AIs were significantly higher, and ATs were significantly lower after the therapy after the therapy with both drugs. RIs in patients treated with valsartane (RI = 0.615 +/- 0.036) are significantly lower than RIs of patients treated with niphedipine (RI = 0.642 +/- 0.030) (p < 0.01) after therapy. Regression analysis for the predictive values of RI, AT, AI in relation to the age-standardized values of systolic and diastolic BP of healthy examinees and patients with hypertension has demonstrated that RI is the strongest and statistically significant predictor in all groups of examinees. Six-months monotherapy of EH with valsartane or with niphedipine is equally efficient in the decrease of the blood pressure, but valsartane has more favourable effect on kidney. Resistance index measured in intrarenal arteries is the best parameter of Doppler spectrum in the evaluation of the effects of antihypertensive therapy on the kidney.

The prognostic value of red blood cell characteristics on diabetic retinopathy development and progression in type 2 diabetes mellitus.

BACKGROUNDAlthough it is considered that the pathogenesis of diabetic retinopathy (DR) in type 2 diabetes mellitus (T2DM) is primarily due to chronic hyperglycemia resulting in vascular changes and retinal ischemia, the red blood cells (RBCs) disorders might also represent an important pathophysiological risk factor.OBJECTIVETo evaluate whether the RBC properties contribute to DR development and progression in T2DM.METHODSThis prospective observational study comprised 247 persons with T2DM free of DR or with non proliferative DR without any signs of anaemia. The patients were reacessed after 60-months.RESULTSThe mean age of our study population was 56 years, 54.9% males with diabetes duration of 11,18±1,28 years. During the follow up, 16 (5.84%) participants developed non proliferative DR and 9 (3.64%) progressed to PDR while the mean corpuscular volume (MCV) and red cell distribution width (RDW) MCV rose. Both MCV and RDW correlated positively with HbA1c (r = 0,468, p = 0.003 and r = 0.521, p < 0.001), while Cox regression analysis revealed that besides age, diabetes duration, HbA1c, hypertension and dyslipidemia presence, MCV and RDW are also associated with the risk of DR development and progression (HR 1.057 and 1.237, p < 0.001).CONCLUSIONSWe clearly demonstrated that RBC's characteristics might represent a risk factor for DR development and progression.

Evaluation of Periodontal Parameters in Patients with Early Stage Chronic Lymphocytic Leukemia.

OBJECTIVE: To assess periodontal conditions in patients with early stage CLL and to compare it with the periodontal status of age matched healthy controls and to analyze the relationship between periodontal and hematological parameters in CLL patients. MATERIALS AND METHODS: 60 subjects were examined: 30 patients with CLL Rai 0 (test group) and 30 age-matching healthy individuals (control group). The exclusion criteria were: presence of other systemic disease or condition (e.g. diabetes), history of treatment for periodontitis, use of antibiotics during the last 3 months, use of medications. Socio-demographic data were obtained by means of a questionnaire. Participants with at least 8 teeth underwent a full mouth examination assessing API, PBI, PPD, REC and CAL. Medical data for CLL patients were collected from the patients' records, while hematological data were obtained from the hemogram. RESULTS: Difference between groups was statistically significant for age, number of teeth and frequency of dental checkups (p<0.05). Patients with CLL had significantly higher average values of periodontal indices (API 0.81±0.18; PBI 2.72±0.68; PPD 3.40±0.53; REC 1.95±0.87, CAL 4.37±0.80) compared to the control group (API 0.69±0.15; PBI 1.91±0.45; PPD 2.51±0.40; REC 0.99±0.54; CAL 3.00±0.58). The correlation coefficients between age and periodontal indices showed statistically significance between age and REC (r=0.357; p<0.01), and age and CAL (r=0.295; p<0.05). Age was not statistically significant covariate for CAL (F=2.205; p>0.05), only for REC (F=4.601; p<0.05). After the removal of the statistical effect of age, the difference in REC between CLL and control group remained statistically significant (F=19.732; p<0.01; eta(2)=0.287). Statistically significant association between periodontal and hematological parameters in CLL patients was not found (p>0.05). CONCLUSION: The results of this study showed that patients with CLL had worse periodontal status compared to healthy subjects. Causal relationship between periodontal and hematological parameters was not proved.

Pleural and pericardial effusions combined with ascites in a patient with severe sunitinib-induced hypothyroidism.

To best of our knowledge, this is the first reported case of pericardial and pleural effusions combined with ascites, precipitated with severe sunitinib-induced hypothyroidism. A 58-year-old man presented in our emergency department due to dyspnoea and dry cough. Sixteen months earlier, the patient underwent left nephrectomy due to metastatic renal cell adenocarcinoma (RCC), and therapy with sunitinib was initiated postoperatively. Thyroid function was not assessed during the therapy. On admission, all laboratory findings were within normal range. Computed tomography of the chest detected voluminous bilateral pleural effusions and mild pericardial effusion, and echocardiography revealed pericardial effusion. Thoracocentesis was carried out three times, and cytological examination showed no signs of malignant cells. After assessment of the thyroid function, neglected hypothyroidism was registered. Substitution therapy with levothyroxine was initiated, and thyroid function normalised 2 weeks later. Few days after the last thoracocentesis, his condition suddenly got worse. Thoracocentesis was repeated, and microbiological analysis of the exudate came positive for Klebsiella pneumoniae and Streptococcus pneumoniae. Despite the implemented therapeutic measures, his clinical condition progressively deteriorated. The patient died 27 days after the admission, hospital-acquired pneumonia was identified as the cause of death. Our case emphasises the necessity of careful monitoring and management of side-effects in patients who receive sunitinib. Hypothyroidism is a known cause of pleural, pericardial and abdominal effusions, as reported in several case reports. Timely initiation of substitution levothyroxine therapy can decrease unnecessary pauses in the therapy with sunitinib, as well as prevent development of severe symptoms.