Safe administration of temozolomide in end-stage renal disease patients.

INTRODUCTION: Glioblastoma multiforme is the most common and aggressive type of central nervous system tumor. We present a novel case of the challenges of dosing temozolomide in a patient with end stage renal disease on peritoneal hemodialysis with unpredictable clearance and toxicities. CASE REPORT: In this case, a 60-year-old male with a past medical history of hypertension and Stage V chronic kidney disease presented with worsening confusion and word-finding difficulty in the emergency department. Magnetic resonance imaging demonstrated a large intra-axial mass within the posterior left frontal lobe measuring 4.5 × 4.1 × 3.5 cm with irregularly, predominant peripheral tumoral enhancement. MANAGEMENT AND OUTCOME: The patient underwent a surgical resection which confirmed the diagnosis of glioblastoma (grade 4). The standard treatment for glioblastoma is 6 weeks of radiation therapy and daily temozolomide. Given his history of renal dysfunction and limited data on the safety of temozolomide in patients on hemodialysis (HD), the patient was administered dose-reduced temozolomide and closely monitored for toxicities. Temozolomide was successfully up-titrated to the full dose. DISCUSSION: Renal replacement therapy is a life-saving treatment for end-stage kidney disease patients. A stepwise increase in the dosage of temozolomide did not increase the risk of toxicity with HD. There are no studies with patients on temozolomide and peritoneal dialysis. Our case transitioned to peritoneal dialysis from HD without significant toxicity from temozolomide. As a more substantial proportion of the population becomes dialysis-dependent in the coming years, we need further studies to understand the safety profiles of chemotherapeutic agents in this complex subset of patients.

Defining the Current Landscape, Attitudes, and Perceived Barriers of Virtual Medicine in Underserved Populations.

PURPOSE: Virtual medicine (VM) use increased during the COVID-19 pandemic as it represented a safe alternative to traditional face-to-face health care delivery. This prospective cross-sectional study aimed to characterize preferences and perceived barriers to VM on the basis of language and specific sociodemographic variables while also identifying particular subpopulations at risk of dissatisfaction regarding VM. METHODS: An institutional review board-approved, 23-item questionnaire was offered in English and Spanish. Examined variables included demographic information, preferences, and perceived barriers regarding VM. Multivariable analysis was performed to determine the association between demographic variables and participants' preferences and perceived barriers. RESULTS: Fewer Hispanic and underserved patients (N = 241) had received oncological care through VM (28.9% v 30.8%) despite comparable preferences and levels of satisfaction regarding the incorporation of VM in health care delivery (21.6% v 25.4%; 68.7% v 82.1%), respectively, with no significant difference by age, level of education, marital status, or Hispanic ethnicity, although Spanish as primary language was statistically significant (P = .001). Although Hispanic and underserved rely more on social media to receive health information (26.5% v 24.7%), they have more technical barriers. They were up to 2.9 times more likely not to have a phone/iPad/similar or access broadband connectivity. CONCLUSION: Given the shift toward outpatient and home-based care, an aging population, and cultural appropriations, VM excitedly allows the reincorporation of family/caregiver in medical engagement. Hispanic patients are equally interested and satisfied in receiving oncological care through VM, but fewer are currently using it. Barriers are predominantly technical and targetable with appropriate policies to help overcome technological barriers on the basis of language, ethnic, locoregional, and sociodemographic variables.

Rare Case of Refractory Hypoxia and Severe Multiorgan Failure from Secondary Lymphohistiocytosis Successfully Bridged to Treatment with Extracorporeal Membrane Oxygenation Support.

Introduction: Acute respiratory distress syndrome (ARDS) is an uncommon complication of hemophagocytic lymphohistiocytosis (HLH). Non-specific findings that mimic other diseases make timely diagnosis and treatment challenging. We present a rare case of severe ARDS and multiorgan failure from secondary HLH due to peripheral T-cell lymphoma. Case presentation: A middle-aged female presented with dry cough and fever for three days. On presentation, the patient was febrile to 105°F and hypoxic to 88% on room air. Chest X-ray showed bilateral interstitial infiltrates. Laboratory investigations showed lymphopenia and elevated inflammatory markers. The viral panel, including coronavirus disease-2019 (COVID-19), influenza, and respiratory syncytial virus (RSV), was negative. Her respiratory status progressively worsened, requiring invasive mechanical ventilation for ARDS. Despite lung-protective ventilation, prone positioning, and the use of paralytic agents, the patient continued to remain hypoxic, necessitating extracorporeal membrane oxygenation (ECMO) support. The patient was started on antibiotics and high-dose steroid. Thereafter, she developed a leukemoid reaction, and the ferritin level started rising; raising suspicion for lymphophagocytosis. During this time, she also developed acute liver and kidney failure and required multiple vasopressors and renal replacement therapy. Eventually, a diagnosis of mature peripheral T-cell lymphoma was established. Subsequently, her respiratory status and multiorgan failure significantly improved, and ECMO was explanted after 2 weeks. She was started on etoposide and steroid, and eventually discharged after 6 weeks. Discussion: This is the first case describing a successful implementation of ECMO in an adult diagnosed with ARDS secondary to mature peripheral T-cell lymphoma; allowing for recovery of respiratory status, which was compromised during the initial cytokine storm and provided time to establish the diagnosis and initiate appropriate treatment of secondary HLH mature due to peripheral T-cell lymphoma, and in the end, prevented a fatality. We believe that ECMO may be appropriately instituted in rapidly deteriorating patients with an unknown illness refractory to conventional therapy, to allow for end-organ recovery, to reach a diagnosis, and to administer appropriate therapy. How to cite this article: Hundal J, Bowers D, Gadela NV, Jaiswal A. Rare Case of Refractory Hypoxia and Severe Multiorgan Failure from Secondary Lymphohistiocytosis Successfully Bridged to Treatment with Extracorporeal Membrane Oxygenation Support. Indian J Crit Care Med 2022;26(8):970-973. Statement of Ethics: This is a case report and does not contain any images or patient identifying information.

Discovery, Significance, and Utility of JAK2 Mutation in Squamous Cell Carcinoma of the Lung.

Lung cancer continues to be the leading cause of cancer-related deaths worldwide. Many studies show lung cancer is a histologically and molecularly heterogeneous group, even within the same histological subtype. Liquid biopsies are a new tool that can identify targetable genomic mutations and impact management. JAK2 p.V617F is a mutation commonly found in myeloproliferative neoplasms but rarely identified in non-small cell lung cancer (NSCLCs). The significance of Janus Kinase (JAK2) mutation in lung cancer is not clearly understood. However, it is thought that it may have a role in treating solid tumors, such as lung cancer. We present two cases of patients diagnosed with NSCLC who were discovered to have JAK2 V617F mutation on liquid biopsy.

Concurrent Lymphoma and COVID-19: Diagnostic and Therapeutic Challenges of High-Grade Lymphoma and COVID-19.

The coronavirus disease 2019 (COVID-19) global pandemic has put an unprecedented strain on cancer care. The initial months were marred by fears of immunocompromised patients becoming opportunistic hosts to this deadly virus. We present a case of newly diagnosed high-grade B-cell lymphoma in a patient with COVID-19 and discuss the diagnostic and therapeutic challenges posed. A 76-year-old female presented with one month of progressive malaise, poor appetite, weight loss, and night sweats. A surveillance COVID-19 polymerase chain reaction (PCR) resulted positive. With strict isolation precautions, the daily focused physical examination masked several key findings including multifocal adenopathy. She developed hypoxic respiratory failure and progressive transaminitis and cytopenias. Image-guided, rather than excisional, biopsy revealed high-grade B-cell lymphoma. Superimposed COVID-19 infection presented multiple challenges, but she completed treatment and achieved remission. Suspicion for underlying malignancy was high. Institutional concerns included obtaining imaging studies and the gold standard excisional tissue biopsy while maintaining acceptable staff exposure. Fortunately, a lymph node core biopsy confirmed the histopathological diagnosis of high-grade B-cell lymphoma. The administration of chemoimmunotherapy (rituximab, cyclophosphamide, doxorubicin, dose-reduced vincristine, and prednisone (R-CHOP)) posed inherent risks, notably, worsening cytopenias and hepatotoxicity. The approach to treatment was further complicated as the interaction of high-grade lymphoma and COVID-19 remained unclear. Medical teams have faced delays executing formerly routine diagnostic studies and formulating timely and appropriate treatment strategies. Careful consideration of risks and benefits must be weighed. A multidisciplinary approach is crucial to successfully treat patients. The relationship between COVID-19 and cancer treatment is yet to be established, and large sample-size studies are required.

Isolated nocardial brain abscess in an immunocompetent patient with lung adenocarcinoma: A case report.

Brain metastases are common in non-small cell lung cancer (NSCLC) and can often be the presenting symptom. However, it is important to consider other etiologies for brain masses even in patients with a malignancy with a propensity to metastasize. We discuss the case of a 60 year-old immunocompetent male who presented with neurologic deficits thought to be secondary to brain metastases in the setting of an incidentally discovered lung cancer. Instead, the mass proved to be a rare isolated Nocardial brain abscess.

Fallopian tube cancer- challenging to diagnose but not as infrequent as originally thought.

Background: Primary fallopian tube carcinoma (PFTC) is a rare gynecological malignancy though its prevalence may be underestimated given that most 'ovarian' serous cancers originate in the fallopian tube. Its diagnosis is challenging due to its vague signs and symptoms on presentation and it is frequently under-diagnosed pre-operatively. Case Presentation: We present a case of a pre-menopausal woman who presented with vaginal bleeding. Her laboratory testing and physical examination were grossly unremarkable. Gynecologic ultrasound demonstrated multiple uterine fibroids and a double layer endometrium measuring 4.5 mm. More importantly, the left ovary was seen with a complex cyst with mildly echogenic fluid and a solid excerscence. These findings were suspicious for malignancy. The clinical and radiological findings with elevated CA-125 were consistent with a malignant process. Patient subsequently underwent a diagnostic laparoscopy, which required conversion to exploratory laparotomy, supracervical hysterectomy, bilateral salpingo-oophorectomy, right ureteral lysis, right para-aortic and right pelvic lymph node debulking and omentectomy. Biopsy of left fallopian tube and ovary revealed invasive high-grade serous carcinoma of fallopian tube, with involvement of lymphovascular spaces and with surface involvement. Peritoneal washings were negative for malignancy. She was diagnosed with a high-grade serous carcinoma of the fallopian tube after undergoing an endometrial biopsy, multiple imaging tests and finally surgical intervention that yielded the diagnosis. She was started on chemotherapy with carboplatin and paclitaxel. Conclusion: Our aim is to highlight the importance of having PFTC among the differential diagnosis when women present with vaginal bleeding or abdominal pain, as the clinical presentation of PFTC tends to be non-specific, and is often under-diagnosed; reviewing the diagnosis and management, and characterizing the similarities and differences of PFTC with other gynecological malignancies such as ovarian cancer.

A Challenging Case of Recurrent Eosinophilic Peritonitis.

Eosinophilic peritonitis is a rare presentation of eosinophilic gastroenteritis and is characterized by eosinophil-rich inflammation in any part of the gastrointestinal tract in the absence of secondary causes of eosinophilia. We report a case of a 48-year-old female who had recurrent hospital admissions due to abdominal pain and distension secondary to relapsing eosinophilic peritonitis.

Concomitant new diagnosis of systemic lupus erythematosus and COVID-19 with possible antiphospholipid syndrome. Just a coincidence? A case report and review of intertwining pathophysiology.

In the midst of the COVID-19 pandemic, further understanding of its complications points towards dysregulated immune response as a major component. Systemic lupus erythematosus (SLE) is also a disease of immune dysregulation leading to multisystem compromise. We present a case of new-onset SLE concomitantly with COVID-19 and development of antiphospholipid antibodies. An 18-year-old female that presented with hemodynamic collapse and respiratory failure, progressed to cardiac arrest, and had a pericardial tamponade drained. She then progressed to severe acute respiratory distress syndrome, severe ventricular dysfunction, and worsening renal function with proteinuria and hematuria. Further studies showed bilateral pleural effusions, positive antinuclear and antidouble-stranded DNA antibodies, lupus anticoagulant, and anticardiolipin B. C3 and C4 levels were low. SARS-Cov-2 PCR was positive after 2 negative tests. She also developed multiple deep venous thrombosis, in the setting of positive antiphospholipid antibodies and lupus anticoagulant. In terms of pathophysiology, COVID-19 is believed to cause a dysregulated cytokine response which could potentially be exacerbated by the shift in Th1 to Th2 response seen in SLE. Also, it is well documented that viral infections are an environmental factor that contributes to the development of autoimmunity; however, COVID-19 is a new entity, and it is not known if it could trigger autoimmune conditions. Additionally, it is possible that SARS-CoV-2, as it happens with other viruses, might lead to the formation of antiphospholipid antibodies, potentially contributing to the increased rates of thrombosis seen in COVID-19.