Treating low- and intermediate-risk acute promyelocytic leukemia with and without chemotherapy: A comparison in a tertiary care center.

Background: Acute promyelocytic leukemia (APL) comprises approximately 10% of acute myeloid leukemia (AML) cases. Material and Methods: Both options of treatment (ATRA-ATO and ATRA-chemotherapy) were discussed with patients with low- and intermediate-risk APL, pros and cons explained in details, and treatment regimen selected after getting informed written consent. Results: Total 71 patients were included in the study; among these patients, 3 were negative for both FISH for t (15,17) and RT-PCR for promyelocytic leukemia retinoic acid receptor alpha, and 36 patients with APL had white blood cell count at diagnosis >10 × 109/l. Total 30 patients with newly diagnosed as low- and intermediate-risk-APL fulfilled all inclusion criteria, treated and followed for a minimum period of 2 years up to June, 2016. Fifteen patients liked to be treated with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), while rest of the 15 patients preferred treatment with ATRA and chemotherapy. Conclusion: Combination of ATRA and ATO is equally effective, less toxic, and more feasible in comparison to ATRA and chemotherapy for patients with low- and intermediate-risk APL and is a viable option for this subset of patients, especially in countries with limited resources.

Use of flow volume curve to evaluate large airway obstruction.

The flow volume loop (FVL) is a graphic display of airflow against lung volumes at different levels obtained during the maximum inspiratory and expiratory maneuver. It is a simple and reproducible method of lung function assessment. A narrative review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, EMBASE, Ovid MEDLINE and CINAHL databases were queried and reviewed for studies pertinent to the various FVLs abnormalities and their mechanisms from January 2020 to December 2020. We used the following search terms; flow-volume loop, upper airway obstruction, Obstructive airway disease, and spirometry.  Assessing the shape of the flow-volume loop is particularly helpful in diagnosing and localizing upper airway obstruction. They are also helpful in identifying bronchodilator response to treatment. Characteristic FVLs is also seen in patients with obstructive or restrictive lung disorders. Spirometry should be interpreted using the absolute values for flows and volumes as well as the flow volume and volume time curves.

COVID-19 vaccine-induced immune thrombotic thrombocytopenia: A review.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible and pathogenic coronavirus responsible for the pandemic coronavirus disease 19 (COVID-19). It has significant impact on human health and public safety along with negative social and economic consequences. Vaccination against SARS-CoV-2 is likely the most effective approach to sustainably control the global COVID-19 pandemic. Vaccination is highly effective in reducing the risk of severe COVID-19 disease. Mass-scale vaccination will help us in attaining herd immunity and will lessen the negative impact of the disease on public health, social and economic conditions. The present pandemic stimulated the development of several effective vaccines based on different platforms. Although the vaccine is safe and efficacious, rare cases of thrombosis and thrombocytopenia following the use of vaccination with the ChAdOx1 CoV-19 vaccine (AstraZeneca, University of Oxford, and Serum Institute of India) or the Ad26.COV2.S vaccine (Janssen/Johnson & Johnson) have been reported globally. This review focussed on the definition, epidemiology, pathogenesis, clinical features, diagnosis, and management of vaccine associated thrombosis.

COVID-19 and coagulopathy.

The SARS-CoV-2 is a new coronavirus responsible for the COVID-19 disease and has caused the pandemic worldwide. A large number of cases have overwhelmed the healthcare system worldwide. The COVID-19 infection has been associated with a heightened risk of thromboembolic complications. Various mechanisms are leading to the high thrombotic risk in COVID-19 patients such as inflammation, endotheliitis, hyperviscosity, and hypercoagulability. We searched PubMed, EMBASE, and CINAHL from January 2020 to December 2020. We used the following search terms: COVID-19, coagulopathy, and thrombosis. We reviewed the epidemiology, clinical features, mechanisms, and treatment of COVID-19-associated coagulopathy.

Severe headache presenting as an early sign of retroperitoneal para aortic paraganglioma.

BACKGROUND: Paraganglioma is a rare type of neuroendocrine tumor with the ability to secrete neuropeptide and catecholamines in excess. Sympathetic hyperactivity, severe persistent headache and hypertension is the most common clinical presentation of paraganglioma similar to pheocromocytoma. Case report We reported a case of 19 year old girl with severe headache and hypertension, from past 6 month. On further imaging evaluation for the headache, the computed tomography of the abdomen plus pelvis was suggestive of left pre para aortic paraganglioma measuring of 3.4 cm in diameter. Surgical excision of mass was done. Histopathological examination of surgical specimen was consistent with the diagnosis of paraganglioma. Patient is on regular follow up without any subjective or objective evidence of the disease. CONCLUSION: Retroperitoneal paraganglioma may be one of the causes for commonly occurring symptomatic headache, which is benign in nature, but possibility of transformation of malignant paraganglioma can occur. The surgical excision of mass is the treatment of choice.

Sanctuary site central nervous system relapse-refractory DLBCL responding to nivolumab and lenalidomide.

Despite improvement in survival in diffuse large B-cell lymphoma (DLBCL) with the introduction of rituximab, central nervous system (CNS) relapse continues to represent a clinical challenge. In diffuse large B-cell lymphoma (DLBCL), the incidence of CNS relapse is only ∼5% in unselected cohorts. Immunotherapy is the treatment that either boosts the patient's own immune system or uses man-made versions of the normal parts of the immune system to kill lymphoma cells or slow their growth. We are presenting a thirty-eight year old man who, presented with neck nodes, axillary nodes, altered sensorium, abnormal body movements, unconsciousness, weight loss and, fever, with a past history of DLBCL in May 2008, treated with 6 cycles of CHOP and completed in November 2008. After 9 years in April 2018, the patient developed similar symptoms and treated with salvage chemotherapy with R-DHAP which was completed in September 2018. Post-treatment PET-CT showed partial metabolic response and we started external beam radiotherapy to initial bulky disease. After completion of radiotherapy, the patient was very reluctant for any type of therapy and went home. After one month he presented to us with persistent vomiting, abnormal body movements and, altered sensorium. On examination, his Glasgow Coma Scale (GCS) was E2V3M2 and he was admitted in Intensive Care Unit. The patient was managed with mannitol, dexamethasone, antiepileptics, antibiotics and other supportive care medicines. His brain magnetic resonance imaging (MRI) was showing multiple heterogeneously enhancing lesions with surrounding vasogenic oedema and his cerebrospinal fluid analysis was positive for malignant cells. He was managed with triple intrathecal chemotherapy with methotrexate 12 mg, Cytarabine 50 mg, and Hydrocortisone 50 mg along with other supportive care medicines, and after 4-5 days he regained consciousness and he was able to talk and understand verbal commands. In view of improvement in general condition and performance status, we started biweekly triple intra-thecal therapy, and Inj. Nivolumab 3 mg per kg q 2 weekly. From the second cycle, we started Lenalidomide 10 mg once a day for 21 days with 7 days gap along with 2 weekly nivolumab and biweekly triple IT chemotherapy. After one month his CSF analysis was negative for malignant cells. Now he is on regular treatment with weekly IT chemotherapy, 2 weekly nivolumab and 3 weeks on and one week off lenalidomide. After 2 months of treatment, his MRI Brain was showing. At the time of submission of this article, he has completed the fifth cycle of immunotherapy and two cycles of lenalidomide. He was able to manage his daily ADL and able to walk with a stick. The patient tolerated immunotherapy, triple IT therapy and lenalidomide very well without much intolerable side effects. Therefore, we concluded that nivolumab and lenalidomide was well tolerated and exhibited antitumor activity in extensively pretreated patients with relapsed or refractory sanctuary site CNS B- cell lymphomas. Additional studies of Nivolumab and lenalidomide in these diseases are ongoing.

Isolated acrometastasis: A rare presenting feature of endometrial carcinoma.

The most common presenting feature of endometrial carcinoma (EC) is abnormal uterine bleeding. Bone metastasis, as a presenting feature of EC, is very unusual which is usually restricted to pelvis and vertebrae. The occurrence of foot metastasis is exceedingly rare. We report a case of a postmenopausal female presented with pain and swelling involving right foot. Biopsy revealed metastatic adenocarcinoma. The patient denied any history of vaginal bleeding or other gynecological symptoms. Bone scan suggested increased uptake in multiple tarsal bones. Uterine curettage confirmed the diagnosis of endometrial adenocarcinoma. The patient was successfully treated with debulking surgery, palliative radiotherapy to the right foot, bisphosphonates, and systemic chemotherapy with marked improvement in local symptoms and is under follow-up for the last 6 months after completion of the treatment. An extensive review of the literature, to the best of our knowledge, did not reveal many cases of acrometastasis as a presenting feature of EC.