Cyclophosphamide, Bortezomib, and Dexamethasone and Severe Systolic Heart Failure: A Case Report.

Multiple myeloma (MM) is a neoplastic proliferation of plasma cells in bone marrow. Pharmacotherapy for the management of patients with MM includes drug classes like proteasome inhibitors, monoclonal antibodies, immunomodulators, alkylating agents, steroids, etc. We present a case of new-onset heart failure with reduced ejection fraction (HFrEF) in a patient with previously normal ejection fraction after treatment with a cyclophosphamide, bortezomib, and dexamethasone (CyBorD) chemotherapeutic regimen. An echocardiogram done after the completion of nine cycles of chemotherapy in a period of about 4.5 months showed severely decreased left ventricular systolic function with an ejection fraction of only 15-20% and grade I diastolic dysfunction. Cardiac catheterization showed no angiographic evidence of vessel occlusion or epicardial disease. HFrEF was managed with the initiation of guideline-directed medical therapy with cardiology clinic follow-up, and the patient was discharged with a plan to start a lenalidomide-based chemotherapeutic regimen with oncology clinic follow-up. It is, therefore, imperative to perform a thorough cardiovascular assessment before initiation of chemotherapy, complemented by periodic and recurrent assessments of cardiovascular function during and after completion of the treatment course, for early detection and prevention of potentially severe cardiovascular toxicities in patients with MM.

Sepsis Unveils T-cell Large Granular Lymphocytic Leukemia in the Setting of End-Stage Renal Disease: A Rare Hematologic Malignancy.

Large granular lymphocytic (LGL) leukemia is a rare chronic lymphoproliferative disorder originating from natural killer cells or T lymphocytes. In this report, we present the case of a 66-year-old female initially treated for sepsis, with methicillin-sensitive Staphylococcus aureus identified on initial blood culture prompting intravenous (IV) antibiotic therapy. The patient met systemic inflammatory response syndrome criteria upon admission due to severe neutropenia. Persistent fever led to neurological symptoms, and imaging revealed lung abnormalities along with chronic changes on the CT scan of the head. Multidisciplinary consultations were sought, resulting in treatment adjustments including antifungals and filgrastim. Flow cytometry and bone marrow biopsy confirmed the diagnosis of LGL leukemia.

Primary Effusion Lymphoma Secondary to Human Herpesvirus 8 (HHV-8) Infection in an Immunocompetent Host: A Case Report.

Primary effusion lymphoma (PEL) is a rare, aggressive, mature type of B-cell lymphoma that usually causes malignant, lymphomatous effusions in the absence of a solid mass. This is commonly seen in immunosuppressed individuals such as those with underlying malignancies, human immunodeficiency virus infection (HIV), cirrhosis, and a history of solid organ transplantation who are infected with human herpesvirus 8 (HHV-8). Clinical presentation varies depending on the extent of disease like shortness of breath, abdominal distention, and typical B symptoms like weight loss, fever, and night sweats. Morphological and immunohistochemical analysis of pleural fluid is required for diagnosis of PEL. Recent case studies are increasingly being reported with cases of PEL presenting in immunocompetent individuals infected with HHV-8. We present a case of PEL in an immunocompetent host and highlight its presentation, diagnosis, and management approaches. Due to the well-known association of PEL with immunocompromised status, the diagnosis is often overlooked in immunocompetent individuals. This case would further highlight the increasing association and the need for clinical vigilance in diagnosing PEL in immunocompetent patients.

Intravenous Hydration and Associated Outcomes in Patients With Sickle Cell Disease Admitted With Vaso-Occlusive Crises: A Systematic Review.

Acute painful vaso-occlusive crisis (VOC) is the common presentation of sickle cell disease (SCD) leading to emergency room visits, admissions, morbidity, mortality, and negative impacts on quality of life. Among various treatment approaches commonly employed to manage the condition, intravenous (IV) hydration is also frequently used in emergency and inpatient settings. Although helpful to overcome dehydration, IV hydration often leads to adverse outcomes like fluid overload, pulmonary edema, increased length of stay, transfer to intensive care unit, new oxygen requirement, etc. Small-scale retrospective studies are conducted to study the outcomes of IV hydration but have failed to conclusively demonstrate its benefits as well as choice of IV fluids, rate of IV fluid replacement, etc. We conduct this review as an attempt to summarize the available evidence on the role and utility of IV hydration in sickle cell crises along with reported adverse outcomes.

A Retrospective Cohort Study From the National Inpatient Sample Database (2016-2019): Does Obesity Affect the Outcomes of Hospitalization Due to Hepatocellular Carcinoma?

INTRODUCTION: Obesity is commonly reported to be associated with hepatocellular carcinoma (HCC) along with higher risks of mortality. However, there is a significant research gap regarding the outcomes of hospitalization due to HCC among obese patients compared to those without obesity. This study compares the outcomes of hospitalization among those two groups. METHODS:  A total of 50,845 patients admitted from 2016 to 2019 with a principal admission diagnosis of HCC were identified using the International Classification of Disease 10 (ICD-10) coding from the National Inpatient Sample (NIS) database. Patients with a body mass index (BMI) >30 were stratified into the obese cohort, and those with BMI ≤30 into the non-obese cohort as per the ICD-10 coding criteria for obesity based on BMI. The primary outcome of the study was mortality, whereas the length of stay, total hospitalization charges, acute kidney injury (AKI), sepsis, and shock were the secondary outcomes. We also compared additional complications such as ascites, portal hypertension, acute liver failure, disseminated intravascular coagulation (DIC), hepatic encephalopathy, and hepatorenal syndrome between the two groups. A multivariate regression model was used to estimate the effect of obesity on outcomes of hospitalization due to HCC. RESULTS: The obese cohort comprised 10.64% of the study population, whereas the non-obese cohort comprised 89.36% of the study population. Compared to the non-obese cohort, the obese cohort of patients with HCC were more likely to have a higher comorbidity index (CCI ≥4: 79.76% in the obese vs 71.17 % in the non-obese cohort). Obesity was found to be a protective factor for in-hospital mortality; that is, the odds of in-hospital mortality among the obese cohort was 0.713 times than that of the non-obese group of patients with HCC. The obese cohort had a higher mean length of stay (6.3 days vs 5.6 days; p value: <0.001) and total hospitalization charges (109,108$ vs 85,406$; p value: <0.001), which was further validated on multivariate analysis. The obese cohort had 1.26 times odds of developing AKI compared to the non-obese cohort (p value: 0.005). Sepsis, shock, and other complications such as acute liver failure, DIC, hepatic encephalopathy, hepatorenal syndrome, and portal hypertension were not significantly different between the two groups. CONCLUSION:  Obesity was associated with reduced in-hospital mortality among patients with HCC. However, obese patients with HCC were found to have higher healthcare resource utilization in terms of length of stay and total hospitalization charge along with the development of AKI. Clinicians should be mindful of the potential longer length of stay and associated complications such as AKI while managing obese patients with HCC. Contrary to commonly held notions, obesity and its relation with in-hospital mortality reported in this study warrants further explorative research.

SARS-CoV-2 and chronic myeloid leukemia: a systematic review.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus causing the coronavirus disease of 2019. The disease has caused millions of deaths since the first pandemic at the end of 2019. Immunocompromised individuals are more likely to develop severe infections. Numerous mutations had developed in SARS-CoV-2, resulting in strains (Alfa Beta Delta Omicron) with varying degrees of virulence disease severity. In CML (chronic myeloid leukemia) patients, there is a lot of controversy regarding the effect of the treatment on the patient outcome. Some reports suggested potential better outcomes among patients with CML, likely due to the use of TKI; other reports showed no significant effects. Additionally, it is unknown how much protection immunization provides for cancer patients. Method: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, we conducted a systematic review. Retrospective, prospective studies, reviews, case series, and case reports of chronic myeloid leukemia patients aged above 18 years who had SARS-CoV-2 infection were included. English literature was screened using PubMed, SCOPUS, and Google Scholar. Search terms include chronic myeloid leukemia, chronic myelogenous leukemia, and SARS-CoV-2 and Coronavirus disease 2019 (COVID-19). We searched the reference lists of the included studies for any new articles. The search included all articles published up to April 20, 2023. The review is registered in PROSPERO (registration number CRD42022326674). Results: We reviewed 33 articles of available published literature up to April 2023 and collected data from a total of 682 CML patients with COVID-19. Most patients were in the chronic phase, seven were in the accelerated phase, and eight were in the blast phase. Disease severity was classified according to WHO criteria. Mortality was seen in 45 patients, and there were no reports of thrombotic events. Two hundred seventy-seven patients were in the era before vaccination; among them, eight were in the intensive care unit (ICU), and mortality was 30 (11%). There were 405 patients after the era of vaccination; among them, death was reported in 15 (4%) patients and ICU in 13 patients. Limitations and conclusion: The major limitation of this review is the lack of details about the use or hold of TKIs during SARS-CoV-2 infection. Additionally, after the appearance of the different variants of the SARS-CoV-2 virus, few studies mentioned the variant of the virus, which makes it difficult to compare the outcome of the other variants of the SARS-CoV-2 virus in patients with CML. Despite the limitations of the study, CML patients with COVID-19 have no significant increase in mortality compared to other hematological malignancy. Hematological cancers are associated with an increased risk of thrombosis, which is expected to increase in patients with COVID-19. However, patient with CML has not been reported to have a significant increase in thrombosis risk. The available data indicates that COVID-19's effect on patients with chronic myeloid leukemia (CML) still needs to be better understood due to the limited data. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php? RecordID:326674.