Review of Hematology-Oncology Emergencies for Internal Medicine Residents.

The prevalence of cancer continues to grow globally every year. With therapeutic advances over the recent decades, the prevalence of individuals living with cancer continues to increase. Internal medicine residents can see patients admitted to the hospital for cancer-related emergencies. Early identification and appropriate management of these emergencies have been shown to improve mortality and morbidity. In this article, we aim to review the recent updates in the management of commonly encountered oncologic emergencies in the practice of internal medicine residents. This review will cover spinal cord compression, superior vena cava syndrome, tumor lysis syndrome, hypercalcemia, pericardial tamponade, hypoglycemia, hyponatremia, bowel obstruction, increased intracranial pressure, leukostasis, hyperviscosity syndrome, neutropenic fever, and hypersensitivity reactions.

Incidental diagnosis of a rare pancreatic plasmacytoma with plasmablastic features.

Multiple myeloma is a plasma cell neoplasm that accounts for 10% of all hematologic malignancies, characterized by malignant proliferation of monoclonal plasma cells in the bone marrow. It predominantly affects men 60 to 70 years of age. Plasmacytoma is a discrete mass of neoplastic monoclonal plasma cells that may be osseous or extramedullary. Though extramedullary plasmacytomas are uncommon, they can involve any tissue or organ. Only a few cases of pancreatic involvement have been reported. We report a case of a 78-year-old woman with a long-standing history of multiple myeloma noted to have pancreatic tail involvement with plasmacytoma with plasmablastic features. Multiple myeloma with plasmablastic transformation has a poor prognosis; hence, a multidisciplinary team approach is crucial to identify and initiate appropriate management in these cases.

Diplopia and Ptosis: An Unusual Case of Prostate Cancer Metastasis to the Sphenoid Bone Treated With Palliative Radiotherapy.

We report a case of a 72-year-old male who presented to the hospital with a chief complaint of diplopia in the setting of a recent onset of urinary incontinence and right-sided back pain. He was subsequently diagnosed with prostate cancer, notably metastasizing to the right sphenoid bone, causing impingement of the oculomotor nerve. Our case is unique in that the patient's initial presentation of prostate cancer was oculomotor nerve palsy with subsequent histologic analysis of the primary tumor showing both small cell neuroendocrine carcinoma along with adenocarcinoma. Also, the initial routine stroke protocol MRI and computed tomography angiography (CTA) missed the lesion, while gadolinium-enhanced targeted MRI revealed lesions in both the spine and the orbit. This case emphasizes the need for enhanced contrast as well as focused imaging in patients presenting with diplopia with a negative initial workup for stroke. Ptosis can be a sign of metastasis from other cancers and it is important to have a broad differential including metastatic disease in patients' presenting with similar symptoms and negative initial workup who may otherwise be at risk of cancer.

Video education about side effects of chemotherapy and immunotherapy and its impact on the anxiety, depression, and distress level of cancer patients.

BACKGROUND: Patients diagnosed with cancer are at higher risk of anxiety, depression, and overall distress. These mood disturbances are risk factors for non-adherence to cancer treatment, increased length of stay during hospital admissions, increased number of visits to the emergency department, and also impact survival. Although paper handouts about the potential side effects are widely used in the oncology practice studies have shown that digital educational material is known to work better when compared to traditional methods. However, the impact of video education on anxiety, depression, and distress have not been previously evaluated. Our study aimed to assess whether video education about potential chemotherapy and immunotherapy can reduce anxiety, depression, and distress levels. METHODS: After IRB approval, we enrolled patients who were fluent in English, younger than 80 years of age, and who were able to provide informed consent. The Hospital Anxiety and Depression Scale and Distress Thermometer were used to assess distress, as well as depression and anxiety before and after watching video educational material. Paired t-test was used to compare the differences between the scores before and after watching educational videos. The statistical software GraphPad Prism 9, San Diego, California, was used to perform the statistical analysis. RESULTS: We enrolled 29 patients, of whom 20 completed the study, six withdrew, two were lost to follow-up, and one did not complete the initial questionnaire. Of all patients that completed the study 85% of the patient found videos helpful, and they were 7/10 likely to recommend them to other patients who may experience symptoms. The mean depression score changed from 4.75 before to 4.9 after watching the videos (p 0.77), distress score from 2.3 to 2.65 (p 0.52), and anxiety scores changed from 4.85 to 6.15 (p 0.03). The feedback provided by the patients indicated that they were more willing to watch the videos related to the side effects they experienced at their free time and convenience. CONCLUSIONS: Our study suggests that patients were open to video education and found it helpful and worth watching. However, the exposure of the patients to the videos about potential side effects of cancer treatment, including those patients do not experience, may lead to increased anxiety.

Thrombotic Thrombocytopenia Masquerading As COVID-19 Infection.

Thrombotic thrombocytopenic purpura (TTP) is a rare and challenging diagnosis that consists of thrombotic microangiopathy due to complete or severe deficiency of ADAMTS13 protease that can present at any age. It is very important to have a suspicion concerning this disease as mortality can be very high if it goes unnoticed. This case describes a patient that presented with gastrointestinal symptoms and hematuria and was found to have COVID-19 and TTP.  We present a case of a 40-year-old female with no past medical history who presented to the Emergency Department with complaints of abdominal pain, nausea, vomiting, and dark urine. The patient workup revealed a platelet count of 4000. The patient was also noted to be COVID-19 positive. Upon further workup, the TTP diagnosis was confirmed. She responded appropriately to plasmapheresis and steroids. COVID-19 seems to be linked to a wide range of hematologic conditions including but not limited to TTP. In view that TTP can have significant mortality if untreated, we must be suspicious about this condition in COVID-19 cases. The aim of this case report is to highlight the importance of having a low threshold for making a diagnosis of TTP if labs are significant for hemolytic anemia. Our aim is also to emphasize that the treatment should be initiated if schistocytes are seen on the peripheral smear without awaiting laboratory results confirming low levels of ADAMTS13, given the fatal nature of the condition if left untreated.

Intussusception Caused by Peutz-Jeghers Syndrome.

A 20-year-old female patient with a family history significant for Peutz-Jeghers syndrome presented to the hospital multiple times with complaints of abdominal pain. On the initial visit to the hospital, the patient underwent small bowel resection for small bowel obstruction secondary to intussusception, following which she visited the hospital again one year later for similar complaints and underwent reduction of multiple points of intussusception of the small bowel without any resection of the same. Eventually, the patient underwent resection of the small bowel for the second time, along with tumor resections. The importance of follow-up in patients with Peutz-Jeghers is particularly essential, in part, because it is vital to monitor the tumors, their size, and number to prevent surgical intestinal complications, anemia, and also to eventually monitor for carcinomatous changes.

A rare case of renal infarction due to heroin and amphetamine abuse: case report.

BACKGROUND: Renal infarctions as a result of recreational drug use are rare and are commonly associated with cocaine use. Although amphetamines have a similar mechanism of action as cocaine, there are few reports linking them to ischemic events, and only one to renal infarction. Similarly, few reports link heroin use with infarcts, but never in the kidney. Although uncommon, several mechanisms have been implicated in heroin and amphetamine-induced infarction, including vasculopathy, vasculitis and the activation of the coagulation cascade. CASE PRESENTATION: 47-year-old female with a past medical history of non-intravenous heroin and amphetamine abuse, chronic obstructive pulmonary disease, hypertension, hyperlipidemia presented with right lower extremity swelling and rash, which was diagnosed as cellulitis and treated appropriately. Incidentally, the patient was found to have an acute kidney injury and further workup identified multiple renal infarcts in the right kidney. The patient had no past medical history of clotting disorders. Blood culture and urine cultures were sterile; autoimmune and hypercoagulable workup were negative. Urinalysis was unremarkable. Urine toxicology was only positive for opiates and amphetamines, which were thought to be the most likely cause of the renal infarct. Patient was lost to outpatient follow up due to noncompliance, but returned to the hospital for re-emergence of her cellulitis, during which no new infarcts were discovered, and the previous renal infarct had scarred over. CONCLUSION: There are very few reports of heroin and amphetamine-induced infarctions. This case report describes a rare but important complication of heroin/amphetamine abuse that could be easily overlooked.

Association of acute thrombocytopenia with anaphylaxis.

A commonly seen phenomenon in the hospital and critical care setting is anaphylaxis. This acute systemic inflammatory reaction can lead to anaphylactic shock in severe cases and potentially be fatal. The role of platelets in anaphylactic reactions is not well established; however, platelets, among other mediators such as platelet-activating factor, have been shown to promote a prothrombotic state shortly after an acute hypersensitivity reaction. In addition, the aggregation of platelets promoted by platelet-activating factor and other mediators can also lead to thrombocytopenia. We present a case of a 57-year-old woman who developed severe anaphylaxis while receiving chemotherapy with paclitaxel suspended in Cremophor, a well-known allergen. She was profoundly thrombocytopenic following the reaction and was treated with therapeutic anticoagulation, with no thrombus formation.

Exploring the Rare Etiology of Severe Anemia in an Immunocompromised Patient.

Pure red cell aplasia (PRCA) is a rare cause of profound anemia, marked by very low reticulocyte count and near to complete absence of erythroid precursor cells in the bone marrow. PRCA can be congenital such as in the case of children with Diamond- Blackfan anemia or acquired, which is often triggered by exposure to certain viruses or drugs. Management depends on the underlying etiology of PRCA. Here, we present the case of a young male with underlying acquired immunodeficiency syndrome, who presented with a hemoglobin of 2.6 g/dL, initially thought to be secondary to gastrointestinal blood loss, but was later discovered to have parvovirus-induced PRCA.

A Rare Case of Inadvertent Iatrogenic Osmotic Demyelination Syndrome.

A 73-year-old African American male presented with altered mental status, severe hyperglycemia, and acute kidney injury. His metabolic derangements including hyperglycemia and hyponatremia were initially thought to be the cause of his encephalopathy. While managing his hyperglycemic hyperosmolar non-ketotic state, he received intravenous rehydration with almost three times his physiologic requirement for normalization of his electrolyte abnormalities. After the correction of the metabolic derangements, he remained confused with dysarthria and labile mood. Magnetic resonance imaging of the brain revealed osmotic demyelination syndrome.

Dermatofibrosarcoma protuberans of the scrotum.

Dermatofibrosarcoma protuberans is a rare tumor that arises in the dermis, with a strong tendency to recur locally. It is slow growing and often presents as a skin-colored plaque on the trunk, although it may arise anywhere on the body. Dermatofibrosarcoma protuberans has a distinctive histologic appearance, and immunohistochemical studies can help make the diagnosis. This case report describes a young man who presented with complaints of an enlarging right scrotal mass and was diagnosed with dermatofibrosarcoma protuberans.

Rapid Development of Pernicious Anemia Unmasking Underlying Gastric Adenocarcinoma.

Gastric cancer is one of the most common malignancies, often detected at later stages as patients remain asymptomatic until later stages. Pernicious anemia (PA), a well-known cause of vitamin B12 deficiency, is a classic risk factor for gastric cancer. Patients with PA usually present with megaloblastic anemia and peripheral neuropathy; however, they can also present with nonspecific symptoms. We describe below the case of a 56-year-old male who presented with symptoms of nausea, vomiting, and fatigue. Initial lab work revealed severe B12 deficiency, pancytopenia, and intramedullary hemolysis warranting endoscopy that revealed a gastric fundus mass significant for adenocarcinoma on biopsy.

A Case of Chronic Right Hip Pain Revealing an Insidious, Incidental Eight-Centimeter Internal Aneurysm Among Multiple Diffuse Aneurysms.

The prevalence of internal iliac artery aneurysms (IIAA) is very low. Existing data on IIAA are scarce and mainly based on case reports and small retrospective series. We present the case of a 55-year-old African American man with a past medical history of HIV, hypertension, pulmonary embolism (PE), chronic obstructive pulmonary disease (COPD), coronary artery disease, polysubstance abuse, schizophrenia, depression, and bipolar disorder who presented to the emergency department with dyspnea on exertion. He was admitted for COPD exacerbation. He reported concerns of ambulatory chronic right hip pain, for which he underwent a CT, which revealed the presence of a partially visible right IIAA. A CT of his abdomen/pelvis revealed multiple aneurysms, including a partially thrombosed 8-cm fusiform right IIAA. Due to the presence of multiple aneurysms, the vascular surgery team was consulted, and elective repair was recommended. IIAA should be considered in the differential diagnosis of patients with significant smoking history and hip pain and acted upon immediately.

A Case Report on Bortezomib-Induced Bilateral Chalazion.

A chalazion is a swollen bump on the eyelid that occurs when the eyelid's oil gland clogs up. Bortezomib is an FDA-approved novel agent for the treatment of patients with multiple myeloma (MM). Recently, there have been a few case reports on the possible association between eyelid chalazion and bortezomib therapy. We describe the case of an 87-year-old female diagnosed with MM who developed bilateral eye chalazion after being initiated on bortezomib. She was evaluated by an ophthalmologist, started on eye lubricants and antibiotic eye drops, and the bortezomib was discontinued until the resolution of the lesions was achieved. Physicians should be aware of these ocular complications of bortezomib, as early intervention can prevent worsening eyelid complications.

Primary Vaginal Malignant Melanoma: A Case Report and Review of Literature.

Primary vaginal malignant melanoma is an extremely rare and aggressive tumor with very few reported cases worldwide. It often occurs in post-menopausal women, with a mean age of 57 years. The most common presenting symptom is vaginal bleeding. Other less common presenting symptoms are vaginal discharge, vaginal mass, and pain. Vaginal melanomas are often diagnosed at an advanced stage, and despite the aggressive treatment approach, the prognosis is poor. We present to you a case of a 56-year-old post-menopausal woman who presented with intermittent vaginal bleeding and passage of dark clots. She was found to have symptomatic anemia requiring blood transfusions. Further workup revealed a mass in the upper vagina on imaging studies, and the patient eventually underwent a biopsy, which confirmed the diagnosis of malignant melanoma of the vagina on pathological examination.

A Rare Case of Small Cell Carcinoma of the Urinary Bladder.

Small cell carcinoma of the bladder is a rare type of bladder malignancy. Based on most of the existing studies, there is an observed male predominance, usually in their sixties or seventies, and they are more likely to have a history of smoking. Additionally, there is a higher predilection for Caucasians (versus non-Caucasians). The most common presenting complaint is painless macroscopic hematuria. However, other presenting symptoms also include dysuria, difficulty voiding, weight loss, abdominal pain, nocturia, and urinary frequency. It is not uncommon to have a history of frequent urinary tract infections, ureteral obstruction, and paraneoplastic syndromes. Cystoscopy is the "gold standard" for evaluation of urinary tract lining, especially in conjunction with narrow-band imaging and biopsy. Transurethral resection of the bladder tumor (TURBT) is the next step in diagnosis and treatment that allows to precisely evaluate pathology and the extent of bladder wall involvement, and is a sufficient surgical approach for the treatment of non-muscle invasive tumors. Once tumor pathology is confirmed, a treatment plan is determined based on the staging. Although both lung and bladder small cell carcinoma have similarities in pathogenesis, genomic alterations in small cell carcinoma of the bladder are more similar to that of urothelial cancer rather than small cell lung cancer. As this is a rare subtype and only a few reported cases are available, no standard treatment regimen has been established. In localized disease, neo-adjuvant platinum-based chemotherapy with cystectomy has been shown to provide the best result in retrospective studies. As this type of cancer has a poor prognosis, in metastatic disease, palliative chemotherapy is offered. Here we present one such case of small cell carcinoma of the bladder and review the current literature.

Development of a monoclonal antibody that specifically detects tissue inhibitor of metalloproteinase-4 (TIMP-4) in formalin-fixed, paraffin-embedded human tissues.

Overexpression of the extracellular metalloproteinase inhibitor TIMP-4 in estrogen receptor-negative breast cancers was found recently to be associated with a poor prognosis for survival. To pursue exploration of the theranostic applications of TIMP-4, specific antibodies with favorable properties for immunohistochemical use and other clinical assays are needed. Here we report the characterization of a monoclonal antibody (clone 9:4-7) specific for full-length human TIMP-4 with suitable qualities. The antibody was determined to be an IgG(2b) immunoglobulin. In enzyme-linked immunosorbent assay (ELISA) and immunoblotting assays, it did not exhibit any detectable crossreactivity with recombinant forms of the other human TIMPs 1, 2, and 3. In contrast, the antibody displayed high specificity and sensitivity for TIMP-4 including in formalin-fixed and paraffin-embedded specimens of human breast specimens. An analysis of tissue microarrays of human cancer and corresponding normal tissues revealed specific staining patterns with excellent signal-to-noise ratios. This study documents TIMP-4 monoclonal antibody clone 9:4-7 as an effective tool for preclinical and clinical investigations.