Delayed Presentation of Malignancy-Associated Pseudoachalasia of the Gastric Cardia.

Pseudoachalasia is a condition in which symptoms, manometry, and imaging findings highly resemble primary achalasia but has a secondary etiology. The majority of patients with pseudoachalasia have the condition as the result of a malignancy, most often at the gastroesophageal junction. There may be issues with timely identification of this malignancy as symptoms are often obscure with diagnostic testing yielding nonspecific results. We describe a case of a 65-year-old diabetic female smoker with a four-month history of intractable vomiting, abdominal pain, and weight loss who was belatedly found to have an adenocarcinoma at the gastric cardia necessitating a total gastrectomy and chemotherapy administration. The case educates clinicians on the clinical alarm symptoms related to malignant pseudoachalasia and stresses the paramount importance of performing a timely esophagogastroduodenoscopy in all cases of achalasia, even with seemingly normal imaging, to rule out pseudoachalasia related to malignancy.

Safety and efficacy of anti-BCMA CAR-T cell therapy in older adults with multiple myeloma: A systematic review and meta-analysis.

INTRODUCTION: Anti-B-cell maturation antigen (BCMA) chimeric antigen receptor T-cell (CAR-T) therapy is transforming the care of patients with relapsed/refractory multiple myeloma (MM). Unfortunately, despite being a disease of older adults these patients remain under-represented in most pivotal clinical trials. We performed a systematic review and proportion meta-analysis of prospective clinical trials and observational studies of anti-BCMA CAR-T therapy in patients with MM with the aim to determine the efficacy and safety of this therapy in older adults (≥65 years). MATERIALS AND METHODS: We searched the Pubmed, Scopus, Web of Science (WOS), Ovid, Embase, CENTRAL, and CINAHL databases through September 9, 2022 and abstracts from the American Society of Hematology (ASH) Annual Meeting 2022. Primary outcome measures included overall response rate (ORR), rates of cytokine release syndrome (CRS), and immune cell-effector-associated neurotoxicity syndrome (ICANS). study was registered with PROSPERO (study number: CRD42022334287). RESULTS: After screening 2218 references, 14 studies were included for data extraction, with a total of 558 patients, 26.2% (n = 146) of whom were older adults. The pooled ORR amongst this population was 93%, which was comparable to the ORR of 86% amongst younger patients. In older adults, the rates of CRS (any grade) and grade ≥ 3 were 95% and 21%, respectively. For younger patients, the pooled rate of CRS (any grade) and grade ≥ 3 CRS was 91% and 20%, respectively. The rate of ICANS (any grade) in older adults was 15%, which was higher than that observed in those <65 years. CONCLUSION: Older adults experience comparable outcomes to younger patients with anti-BCMA CAR-T therapy, albeit with numerically higher rates of neurotoxicity.

Extramedullary Acute Myeloid Leukemia Presenting With Pericardial Effusion and Arrhythmias.

Acute myeloid leukemia (AML) is a hematologic malignancy that, through clonal transformation, results in abnormal proliferation and accumulation of immature myeloid cells in the bone marrow and blood. It is the most common type of acute leukemia in adults; however, extramedullary relapse is rare, and clinically significant metastasis to the heart with multiple presentations is even more infrequent. We present a case of a patient with AML, who, after successful treatment and remission, was found to have extramedullary metastasis in the form of one pericardial and two intracardiac masses, as well as a large pericardial effusion and conduction abnormalities.

A Case of Symptomatic Supratherapeutic International Normalized Ratio on Rivaroxaban.

Rivaroxaban is a direct oral anticoagulant that works by inhibiting factor Xa. Direct anticoagulants have largely replaced direct vitamin K inhibitors (VKAs) due to the decreased risk of major hemorrhages and the lack of need for regular monitoring and dose adjustments. However, there have been multiple reports of elevated international normalized ratio (INR) and bleeding incidents in patients on rivaroxaban, which brings into question the potential need for monitoring. We report a case of an INR of 4.8 in a rivaroxaban-naïve patient who presented with gastrointestinal bleeding and a significant drop in hemoglobin four days after starting rivaroxaban. We present possible pharmacologic explanations. We propose the idea that specific subgroups of patients may be at risk for true INR elevations and may benefit from routine monitoring of their INR while on rivaroxaban.

Pituitary Apoplexy Following Elective Total Hip Replacement.

Pituitary apoplexy is an endocrine-related emergency most commonly caused by hemorrhage into a preexisting pituitary adenoma. Known risk factors for such hemorrhage include major surgical procedures, head trauma, pregnancy, anticoagulation, and the administration of hormone therapies for the correction of primary hypothalamic deficiencies. Elective orthopedic surgery is an uncommon precipitator of pituitary apoplexy that is rarely described. We report the case of a patient with a previously unknown pituitary macroadenoma who developed apoplexy as a complication of elective right total hip arthroplasty.

Eustachian Valve Endocarditis in a Patient With Charcot-Marie-Tooth Disease.

Endocarditis is a serious infectious disease of the endocardial surface of the heart, predominantly involving the heart valves, and it results from the colonization and proliferation of microorganisms within the bloodstream. The condition primarily affects individuals with underlying cardiac abnormalities or those who have undergone invasive procedures. Symptoms may include pyrexia, fatigue, arthralgia, and new cardiac murmur. We present a case of a young male patient who had recently undergone surgery and developed eustachian valve endocarditis (EVE), a condition scarcely described in the literature.

Eculizumab in the Treatment of Gemcitabine-Induced Atypical Hemolytic Uremic Syndrome.

Gemcitabine-induced hemolytic uremic syndrome is an often-missed condition. We present a case outlining the successful management of a patient with metastatic cholangiocarcinoma treated with gemcitabine who subsequently developed hemolytic uremic syndrome. Early recognition and stopping gemcitabine are essential in this patient population. Complement inhibitors have been used, and our patient improved on eculizumab therapy.

Hypercholesterolemia due to lipoprotein-X manifesting as pseudohyponatremia in a patient with cholestasis.

Pseudohyponatremia is an often misdiagnosed condition that needs to be managed by addressing the underlying cause. Treatment of hyponatremic patients with intravenous fluids without ruling out pseudohyponatremia may aggravate a patient's hyponatremia and result in adverse outcomes. In a patient whose sodium is deteriorating, it is critical to diagnose pseudohyponatremia early in the course and acquire necessary consultations, even if the patient is asymptomatic. We discuss a case of a man in his 20s with a history of liver transplantation who presented with unexplained dangerously low sodium while being asymptomatic. The case illustrates an uncommon cause of pseudohyponatremia due to lipoprotein-X hypercholesterolemia in a patient with cholestatic liver disease.

Early orbital involvement in a rare diagnosis of Burkitt-like lymphoma with 11q aberration.

Burkitt-like lymphoma with 11q aberration is a rare condition that poses a diagnostic challenge due to similarities with Burkitt's lymphoma. Due to the rarity of cases, no specific guidelines exist for therapy, and it is treated the same way as Burkitt's lymphoma. We present such a case with initial orbital involvement, an unusual manifestation. Our patient achieved remission with induction chemotherapy, although he will need regular follow-up given the paucity of information on long-term monitoring in these patients.

Diffuse Large B-Cell Lymphoma of the Cecum.

Lymphoma when arising from sites other than lymph nodes is termed extranodal lymphoma, commonly affecting the gastrointestinal tract. Primary colorectal lymphoma is a rare phenomenon among malignancies affecting the colon. We report a case of a patient with a history of Burkitt lymphoma in remission, presenting with a large cecal mass and a new diagnosis of diffuse large B-cell lymphoma treated with chemotherapy.

Carfilzomib-Induced Tumor Lysis Syndrome and Biventricular Heart Failure in a Patient With Multiple Myeloma.

Carfilzomib is a proteasome inhibitor (PI) used in multiple myeloma (MM) that is resistant to other therapies. Despite its efficacy and potency, carfilzomib has been associated with kidney injuries, cardiovascular toxic effects, and hematological adverse events. Tumor lysis syndrome (TLS) following the use of PIs in MM, a malignancy not known to cause TLS, has seldom been reported. We present a case of a patient with a known diagnosis of MM who received prior therapy including bortezomib, a first-generation PI, developing worsening heart failure and new onset TLS days after the administration of carfilzomib.

Avapritinib for the treatment of KIT mutation-negative systemic mastocytosis.

Systemic mastocytosis results from the spread of abnormal mast cells in different parts of the body, with variable clinical presentation. It is difficult to diagnose and to determine the appropriate therapy regimen. We present a case of a 53-year-old man diagnosed with KIT-negative advanced systemic mastocytosis based on the 2016 World Health Organization criteria. The patient presented with widespread symptoms that continued to worsen despite supportive therapy and traditional tyrosine kinase inhibitors. He was ultimately started on avapritinib, which reduced his tryptase level and provided symptomatic relief many years after his diagnosis.

The Neurotoxic Mechanisms of Graphene Family Nanomaterials at the Cellular Level: A Solution-based Approach Review.

The graphene family nanomaterials (GFNs) have been recognized to have potential applications in biomedicine, especially in the rag nostic, drug delivery and neuroimaging. Multiple studies have examined the neurotoxicity of GFNs to assay their toxic effects on organisms and ecosystems. In this article, we reviewed the different neurotoxicity effects of GFNs at intracellular levels, including nucleus-related effects and cytosolic mechanisms, as well as extracellular levels, including effects on enzyme activity, oxidative stress, behavior, neurotransmitters, and central nervous system (CNS). Furthermore, for the sake of the solution, we discussed the reducing ways of graphene toxicity. A schematic description is shown in Fig. (1).

Venetoclax and Azacitidine in the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm Refractory to Conventional Therapy.

Blastic plasmacytoid dendritic cell neoplasm is a rare and aggressive hematological malignancy associated with poor prognosis and limited treatment options. No guideline-directed therapy existed until the approval of tagraxofusp in 2018 by the Food and Drug Administration. Multiple clinical trials are undergoing as treatment options continue to evolve. We report a case refractory to tagraxofusp and pivekimab sunirine with subsequent remission achieved on venetoclax and azacitidine therapy.

Pulmonary Arteriovenous Malformation in a Rare Case of Hereditary Hemorrhagic Telangiectasia.

Hereditary hemorrhagic telangiectasia is a rare condition presenting with anemia requiring transfusion and nosebleeds often refractory to supportive therapy. We discuss a case of a male in his 60s with a history of epistaxis, anemia requiring transfusions, and acute on chronic worsening shortness of breath presenting for evaluation. He was diagnosed with hereditary hemorrhagic telangiectasia. In addition, he was found to have pulmonary arteriovenous malformations and nonbleeding gastric telangiectasias. The patient underwent coil embolization of pulmonary arteriovenous malformations with a resolution of his shortness of breath and his anemia improved with iron supplementation.

Ponatinib-Induced Cerebrovascular Accident (CVA).

Ponatinib is a highly potent tyrosine kinase inhibitor shown to have excellent outcomes in the treatment of acute and chronic leukemias. Despite its high efficacy, ponatinib has been shown to carry an increased risk for cardiovascular adverse events, not attributable to a known mechanism. We present a case of a patient with Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL) who developed a cerebrovascular condition while receiving maintenance therapy with the lowest treatment dose of ponatinib for a prolonged duration.