Immune Checkpoint Inhibitor-Induced Pure Red Cell Aplasia: A Review of 2 Cases in Metastatic Melanoma.

BACKGROUND Immunotherapy is a novel treatment offering an alternative to traditional chemotherapeutic agents for different malignancies. Hematologic adverse reactions (HARs) related to immune checkpoint inhibitors (ICIs) are uncommon. Pure red cell aplasia (PRCA) is a rare hematologic complication of ICI therapy in metastatic melanoma with significant mortality risk despite treatment with steroids or immunosuppressive therapy. For unexplained acute anemia after exclusion of other causes, performing bone marrow biopsy is imperative to diagnose PRCA and rule out involvement of bone marrow by primary tumor. HARs can occur during ICI therapy or even after ICI therapy is stopped. ICI rechallenge, even after the development of HARs, is considered in some patients with good response to treatment of HARs from ICIs. Recurrence of HARs with the same or different type of reaction is seen in some patients. CASE REPORT Two cases of ICI-induced PRCA were confirmed on bone marrow biopsy after dual ICI treatment with nivolumab and ipilimumab in metastatic melanoma. In case 2, PRCA was successfully treated with steroids and later rechallenged with single-agent nivolumab, causing mild ICI-induced immune thrombocytopenia, which did not require treatment with steroids. CONCLUSIONS It is crucial to increase clinician awareness of the possibility of PRCA development not only during treatment with ICI but also after finishing treatment with ICI; there is high mortality associated with missing an opportunity to diagnose and treat PRCA on time with favorable results. ICI rechallenge can be considered in patients who showed response to immunotherapy, especially those with limited alternative therapeutic options.

Pneumothorax, pneumomediastinum, and subcutaneous emphysema in hospitalized COVID-19 patients: incidence, clinical characteristics, and outcomes.

BACKGROUND: Limited data is available on the incidence and outcomes of pneumothorax (PTX), pneumomediastinum (PNM), and subcutaneous emphysema (SCE) in COVID-19 patients. This study aimed to investigate the characteristics of these complications in hospitalized COVID-19 patients. RESEARCH DESIGN AND METHODS: A retrospective study was conducted, involving adult COVID-19 patients admitted to Mayo Clinic Florida from 03/2020-06/2022. Patients were divided into two groups based on the presence or absence of PTX/PNM/SCE. RESULTS: 1926 hospitalized patients with COVID-19 were included, of which 518 were admitted to the ICU. The incidence of PTX/PNM/SCE was 6.3%. Patients with these complications were more likely to be male, Asian, and unvaccinated. Conversely, they were less likely to have chronic obstructive pulmonary disease. Patients who developed PTX/PNM/SCE after 72 hours of admission were more likely to receive high-dose corticosteroids and for an extended duration. The affected group had an adjusted odds ratio for in-hospital mortality of 13.32 (95%CI, 8.19-21.59) and ICU admission of 9.14 (95%CI, 5.3-12.78) compared to the unaffected group. CONCLUSION: Although the occurrence of PTX/PNM/SCE in hospitalized COVID-19 patients was rare, it was associated with worse outcomes. Corticosteroids may contribute to the pathogenesis of these complications; however, further studies are needed to investigate this relationship in more detail.

Suppurative Thrombosis of the Portal Vein (Pylephlebits): A Systematic Review of Literature.

Suppurative portal vein thrombosis (pylephlebitis) is an uncommon condition usually associated with an intra-abdominal infection or inflammatory process. In this study, we aimed to synthesize data on previously published cases according to the PRISMA guidelines. A total of 103 patients were included. Patients were more commonly male (71.8%) and had a mean age of 49 years. The most common infection associated with pylephlebitis was diverticulitis (n = 29, 28.2%), and Escherichia coli was the most isolated pathogen (n = 21, 20.4%). Blood cultures were positive in 64 cases (62.1%). The most common site of thrombosis was the main portal vein (PV) in 59 patients (57.3%), followed by the superior mesenteric vein (SMV) in 40 patients (38.8%) and the right branch of the PV in 30 patients (29.1%). Sepsis developed in 60 patients (58.3%). The mortality rate in our review was 8.7%, and independent risk factors for mortality were the presence of pertinent comorbidities (OR 5.5, p = 0.02), positive blood cultures (OR 2.2, p = 0.02), and sepsis (OR 17.2, p = 0.049).

Celiac Disease and Thrombotic Events: Systematic Review of Published Cases.

Extraintestinal manifestations of celiac disease (CD) should be considered, even in patients without typical intestinal symptoms. The aim of our study is to examine the literature regarding the occurrence of thrombotic events in CD, and to synthesize the data from case reports and case series. A systematic review of the literature was conducted by searching the Pub-Med/MEDLINE database, from the date of database inception to January 2022, to identify published cases and case series on this topic, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 55 cases were included in the study. The majority of patients were previously healthy individuals, with no comorbidities. In less than one-third of the cases (30.91%), the diagnosis of CD was established before the onset of thrombosis, while in the remaining cases (34.54%), thrombosis preceded the diagnosis or was diagnosed concomitantly with CD. The most common sites for thrombosis occurrence were hepatic veins (30.91%), while thrombosis of cerebral blood vessels, deep venous thrombosis of lower extremities, and pulmonary thromboembolism were less frequent. Thrombosis was most commonly isolated to one site only (78.18%). In 69.09% of cases (n = 38), some form of anticoagulation, along with a gluten-free diet, was initiated.

A novel approach using sorafenib in alpha fetoprotein-producing hepatoid adenocarcinoma of the lung.

Hepatoid adenocarcinoma of the lung (HAL) is an extremely rare cancer without clear treatment guidance and with a poor prognosis. This report discusses a 64-year-old man who presented with complaints of hemoptysis and was found to have a right upper lobe (RUL) lung mass on chest CT with presence of a right hilar mass and retrocaval lymphadenopathy, and metastasis to the vertebral spine and rib. The patient was diagnosed with T2N2M1 (stage IV) unresectable disease. A biopsy of the RUL mass revealed hepatoid variant adenocarcinoma. Immunohistochemical stains showed tumor cells positive for CK7, AFP, Hep Par 1, napsin A, and cytoplasmic TTF-1 staining. In contrast, CK5, CK6, and CK20 were negative, and EGFR was wild-type. Serum alpha fetoprotein (AFP) level was elevated at 181 ng/mL. The patient was treated with platinum-based doublet chemotherapy and sorafenib, and his AFP level decreased to 25 ng/mL. This case report presents the novel use of sorafenib in combination with platinum-based doublet chemotherapy in EGFR wild-type HAL, which led to a partial response. Single-agent sorafenib led to stable disease overall, achieving a survival among the longest reported for unresectable stage IV, all while maintaining an ECOG performance status of 0 to 1.

Medical waste management at the Oncology Institute of Vojvodina: possibilities of successful implementation of medical waste regulation in Serbia.

Implementation of National waste management strategy, which included most of Healthcare facilities (HCF) in Serbia, began in 2009. The present study aimed to evaluate the medical waste management strategy protocol at Oncology Institute of Vojvodina, which is the first institution in Vojvodina and one of the first institutions in Serbia which has implemented the recomended medical waste management protocol. Segregation, storage, transportation and treatment were all evaluated and that was all performed according to National strategy. Biohazard generation rate was 0,17 kg/bed/day, which correspods with values in the HCF in Eastern Europe. The results show that the methods for safe management of medical waste are acceptable, affordable, and economically justifable to accomplish the reduction in the financial costs in HCF business, and can serve as representative of proper medical waste management practice for other HCF.