Viral Infections and Incidence of Reactivations in Chronic Myeloid Leukemia Patients.

BACKGROUND: Viral infections remain a significant problem for patients with chronic myeloid leukemia (CML) who undergo stem cell transplants (SCTs). These infections often result from the reactivation of latent viruses. However, our understanding of the risk of viral reactivation in CML patients who have not undergone SCT is limited, and there is a scarcity of data on this topic. Tyrosine kinase inhibitors (TKIs) have revolutionized the treatment of CML as it is highly successful and has transformed the prognosis of patients with CML. However, TKI may be associated with an increased risk of infections. SUMMARY: We have performed a literature search for publications related to viral infections and their reactivations in patients with CML using PubMed, Scopus, and Google Scholar for the period 2001-2022. The population consisted of patients over 18 years old with a diagnosis of CML and no history of bone marrow transplantation. In an analysis of 41 patients, with 25 males and 16 females, M:F ratio of 1.56:1, and a median age of 50. Age ranged from 22 to 79 years. Most patients with reported viral infections or reactivations were in the chronic phase (CP) of CML, with 22 patients (76%) in the CP, 6 patients (21%) in the accelerated phase, and 1 patient (3%) in the blast phase. Most cases with reported outcomes responded to treatment for CML; only one had refractory disease and 8 cases (32%) had major molecular response. Imatinib was the most used TKI in 31 patients (77%). The most reported viral reactivations were herpes zoster in 17 cases (41%), followed by hepatitis B reactivation in 15 cases (37%). KEY MESSAGES: This review sheds light on the importance of having a hepatitis B serology checked before starting TKI therapy and close monitoring for viral infections and reactivations in patients with CML.

Romiplostim use for thrombocytopenia following allogeneic hematopoietic stem cell transplantation: a case series from a single center in Qatar.

Thrombocytopenia is a common and serious complication that can occur following hematopoietic stem cell transplantation (HSCT), and it contributes to increased morbidity and mortality. The mechanisms of post-HSCT thrombocytopenia are multifactorial and complex. There are no clear consensus and guidelines for managing thrombocytopenia post-HSCT. Recently, there has been promising use of thrombopoietin receptor agonists (TPO-RAs), particularly eltrombopag and romiplostim, as treatments for post-HSCT thrombocytopenia. Notably, that this indication is considered off-label, and data in this use are limited. Based on the existing body of evidence, romiplostim emerges as a safe and effective option for individuals with transfusion-dependent thrombocytopenia after HSCT. In this context, we present a summary of our experience at a single center, where romiplostim was used in the management of post-HSCT thrombocytopenia due to poor graft function. Notably, all four cases responded positively to romiplostim treatment, and no significant adverse events were observed.

Osteolytic bone lesions as an initial presenting manifestation of adult acute lymphoblastic leukemia: a mini review.

Hematological malignancies can lead to bone lesions, and the most common example is the osteolytic lesions found in multiple myeloma. Cases of osteolytic lesions have been rarely reported in acute lymphoblastic leukemia (ALL), non-Hodgkin lymphoma, Waldenström macroglobulinemia, chronic lymphocytic leukemia, acute myeloid leukemia, and myeloproliferative neoplasms. This review sheds light on the association between ALL and osteolytic bone lesions. To our knowledge, we found 15 cases of patients with ALL who developed osteolytic lesions. Most patients were males with a median age of 29 years. B-cell ALL was the most common type of ALL associated with osteolytic lesions. All patients presented with bone pain, and hypercalcemia was found in 80% of the reported cases. Osteolytic lesions were detected by plain radiography (X-ray) in approximately half of the patients; computed tomography, MRI, or PET scans confirmed the osteolytic lesions in the remaining patients. The axial skeleton was mainly affected. Based on our review, there was no association between osteolytic bone lesions and the Philadelphia chromosome. There are no case of spinal cord compression in adults ALL patients attributed to osteolytic lesions of the vertebra. The majority of patients received chemotherapy, and the outcomes among these patients were variable. Almost all of them achieved complete remission. However, two patients developed a disease relapse. Given that our review is solely based on case reports, we could not conclude if the presence of osteolytic bone lesions is a prognostic factor for adverse outcomes or indicates an 'aggressive' form of ALL.

Thyrotoxic periodic paralysis as the first presentation of Graves' disease: A case report.

Thyrotoxic periodic paralysis (TPP) is a rare disease seen predominantly in men of Asian origin. It should be considered in the differential diagnosis of patients with acute onset of weakness, and it is reversible after the correction of serum potassium. TPP can rarely be the initial presentation of Graves' disease.

Pediatric Philadelphia-Negative Myeloproliferative Neoplasms in the Era of WHO Classification: A Systematic Review.

BACKGROUND: Philadelphia-negative myeloproliferative neoplasms (MPN) are most prevalent in the older population (median age at the diagnosis is above 60 years) and rarely diagnosed in pediatrics. Thus, our knowledge about the clinical presentation, mutational status, and complications of MPNs in pediatrics is limited. METHODS: The literature in English (PubMed, SCOPUS, and Google Scholar) was searched for studies, reviews, case series, and case reports of patients with Philadelphia-negative MPNs (including essential thrombocythemia, polycythemia vera, primary myelofibrosis, and profibrotic myelofibrosis) in the pediatrics age group (less than 18 years). Only studies that fulfilled WHO 2008 or 2016 criteria for MPNs were included. We aimed to describe the clinical characteristics, vascular and long-term complications, types of driver mutations, and treatment approaches in pediatric patients with MPNs. RESULTS: We reviewed 33 articles of available published literature from 2008 to 2022 and collected data from a total of 196 patients of the pediatric population. Among the cohort of patients, 139 had essential thrombocythemia (ET), 20 had polycythemia vera (PV), and 37 had primary myelofibrosis (PMF). The median age at the time of diagnosis for each disease varied, with 8.8 years for ET, 10 years for PV, and 3.6 years for MF. There was a slight difference in gender prevalence between both gender groups and all three diseases. The presenting symptoms were not mentioned in more than 50% of studies. We found that JAK2 was the most prevalent among all mutations. Both bleeding and thrombosis were present equally in ET, with 9% of cases complicated by bleeding and 9% complicated by thrombosis. Hemorrhagic events did not occur in patients with PV; thrombosis in children with MF was also not found. The progression into AML occurred in two patients with PV and one with ET. CONCLUSION: Given the rarity of MPNs in pediatrics and their different characteristics compared with adults, we believe there is a need for unique diagnostic criteria to match the different molecular statuses in pediatrics. Based on our review, the incidence of MPN complications in pediatrics, including thrombotic events, hemorrhage, and leukemic transformation, differs from that in adults.

Prostate adenocarcinoma presenting as diffuse osteolytic metastasis.

Prostate cancer is one of the most common cancers that metastasize to the bone. Bone metastasis is usually osteoblastic, and diffuse osteolytic lesion on presentation is unusual. Here, we are reporting MRI image of patient presented with diffuse osteolytic lesion and found to have metastatic prostate cancer.

Pulmonary actinomycosis as a cause of chronic productive cough in a heavy smoker male with poor dental hygiene: A case report.

Pulmonary actinomycosis is a rare chronic granulomatous bacterial disease caused by Actinomyces species. Given its nonspecific clinical and radiological manifestations, the diagnosis might be delayed or even missed. Pulmonary actinomycosis mimics tuberculosis, aspergillosis, or malignancy both clinically and radiographically, and it should be considered in patients with chronic lung diseases.

Non-diabetic ketoacidosis secondary to primary hyperthyroidism: A case report.

INTRODUCTION: There are variable complications of hyperthyroidism, including atrial fibrillation, heart failure, osteoporosis, and thyroid storm. One infrequent complication of hyperthyroidism is non-diabetic ketoacidosis (NDKA). To the best of our knowledge, our case is the third report of NDKA related to thyrotoxicosis. PATIENT CONCERN: We describe a case of a 41-year-old African lady with no past medical history presented to our hospital with severe abdominal pain and vomiting for three weeks. This was associated with decreased appetite and weight loss. DIAGNOSIS: Laboratory findings were significant for high anion gap metabolic acidosis, positive ketones in the urine, and high serum B-hydroxybutyrate. The blood glucose readings and HbA1c were within normal limits. Also, serum lactic acid and salicylate levels were within the normal range. The diagnosis of NDKA was made. Later, the thyroid functions test (TFT) confirmed the diagnosis of primary hyperthyroidism. INTERVENTION AND OUTCOMES: The patient was managed initially with intravenous fluid and antiemetics. Then, she was started on propranolol and carbimazole. After which, her symptoms improved dramatically, and the metabolic acidosis (with serum ketones) were corrected within a few days of starting anti-thyroid medications. CONCLUSION: Despite its rarity, NDKA can be associated with severe thyrotoxicosis. Vigorous intravenous hydration and anti-thyroid medication are the mainstay treatment. TFT should be requested in a patient with unexplained NDKA.

Mycobacterium abscessus urinary tract infection in an immunocompetent host: A case report and literature review.

Mycobacterium abscessus is one of the nontuberculous mycobacteria (NTM), which can cause many clinical spectra, predominantly pulmonary infections followed by skin and soft tissue infections. The prevalence of Mycobacterium abscessus infections has been growing worldwide over the last two decades. Urinary tract infection (UTI) secondary to M. abscessus is a rare condition, and only five cases have been described in the literature so far. Therefore, managing such a condition is challenging and based on limited evidence. Here, we report a case of an adult male with a history of previous urological procedures who presented with lower urinary tract symptoms (LUTS) and was found to have a UTI secondary to Mycobacterium abscessus. In this case, we described our successful management approach of this rare entity of Mycobacterium abscessus infection, and we reviewed similar cases in the literature.

Recurrent spinal cord compression due to extramedullary hematopoiesis in thalassemia patient: Case report.

INTRODUCTION: Spinal cord compression secondary to extramedullary hematopoiesis (EMH) is a rare condition. Variable treatment options have been reported with different efficacy and recurrence rate. Due to its rarity, no clear optimal management guidelines have been established yet. PATIENT CONCERNS AND DIAGNOSIS: We report a recurrence of spinal cord compression secondary to EMH in a 19-year-old male, with a background of transfusion-dependent beta-thalassemia on luspatercept, who presented with weakness in both lower limbs. INTERVENTIONS AND OUTCOMES: He was treated successfully both times with radiotherapy. CONCLUSION: Early diagnosis and management of EMH compressing the spinal cord are essential to prevent permanent neurological damage. Diagnosis should be suspected based on the clinical presentation and magnetic resonance imaging findings in a patient with a history of ineffective hemopoiesis. Treatment option remains controversial. Radiotherapy option seems effective, even in recurrent cases, and valid, particularly for those at high risk of surgery or who do not prefer it.

Avascular necrosis in patients with chronic myeloid leukemia: A systematic review.

Objective: Avascular necrosis (AVN)has been encountered in hematological malignancies; nonetheless, AVN is extremely uncommon in patients with chronic myeloid leukemia (CML). This review aims to describe the pathophysiology, clinical characteristics, and outcomes of AVN in CML. To our knowledge, this is the first systematic review of this topic. METHODS: We searched PubMed and Google Scholar for the case reports and series of patients with CML who developed AVN from inception to July 2021. RESULTS: We found 21 cases of AVN in CML patients,17 cases with avascular necrosis of the femoral head (AVNFH), and four cases with osteonecrosis of the jaw (ONJ). The median age was 39 years with an almost equal distribution between males and females (ratio of 1:1). AVN related to CML management has been linked to tyrosine kinase inhibitors (TKIs) and standard interferon-alpha (IFN-α) therapies. Only six (out of 17) patients who developed AVN of the femoral head eventually required a hip replacement, and one (out of 17) developed a recurrent episode of AVNFH. All the reported cases of CML with osteonecrosis of the jaw were associated with TKIs therapy. CONCLUSION: Clinician should consider AVN in any CML patient complaining of either hip or jaw pain. IFN-α and TKI therapies can predispose to AVN in CML patients. Further studies are required for a better understanding of this condition in CML.

Disseminated tuberculosis complicated by hemophagocytic lymphohistiocytosis in an immunocompetent adult with favorable outcomes: A case report.

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory syndrome characterized by excessive activation of macrophages and T-cells with high cytokines levels, causing multiorgan dysfunction.HLH has been associated with variable infectious etiologies, such as tuberculosis(TB). TB-associated HLH (TB-HLH) is a rare condition, but it is fatal if not treated. The diagnosis of TB-HLH is challenging and might be missed if not highly considered. The classic manifestations of HLH include pancytopenia, organomegaly, lymphadenopathy, and coagulopathy. Herein, we present a young immunocompetent adult diagnosed with disseminated TB complicated by HLH. Our patient responded well to the combination of antituberculosis therapy(ATT), corticosteroid, and intravenous immunoglobulin(IVIG). This case highlights the importance of considering this fatal complication in TB patients.

Ruxolitinib (a JAK2 inhibitor) as an emerging therapy for refractory pruritis in a patient with low-risk polycythemia vera: A case report.

INTRODUCTION: Polycythemia vera (PV) is a Philadelphia-negative myeloproliferative neoplasm (MPN) characterized by the overproduction of red blood cells. The presence of JAK2 mutation is detected in up to 99% of patients with PV. Pruritis is commonly encountered in patients with PV and is considered the most troublesome symptom. Multiple treatment modalities are used for treatment; however, their efficacy is variable. Sometimes, pruritis will not improve even by the use of combined therapies. Recently, Ruxolitinib (a JAK2 inhibitor) has been shown to be very effective, especially in patients with refractory pruritis in the setting of other treatment modalities failure. PATIENT CONCERN: We describe a 55-year-old male with history of low risk PV presented with severe itching despite using different therapies, including phlebotomy and hydroxyurea. His laboratory results on presentation were significant for red blood cells (RBC) of 8.2 × 106/uL (normal = 4.5-5.5), hematocrit (Hct) of 52.8% (normal = 40-50%), platelet count of 519 × 103/uL (normal = 150-400), white blood cells count of 12.3 × 103/uL (normal = 4-10), and basophils count of 0.22 × 103/uL (normal < 0.1). DIAGNOSIS: PV related refractory pruritis. INTERVENTION: Pruritis improved dramatically after starting Ruxolitinib therapy with an improvement of hematological parameters (both hematocrit and platelet count). CONCLUSION: Different treatment modalities have shown to be beneficial in treating PV-related pruritis, but the clinical outcomes are highly variable. This case report aims to shed light on Ruxolitinib as an emerging therapy for the treatment of refractory cases of PV-related pruritis.

Rebound of platelet count in a patient with type 2 calreticulin-mutant essential thrombocythemia in the postpartum period: A case report.

INTRODUCTION: Essential thrombocythemia (ET) is an uncommon myeloproliferative neoplasm. It is more common in females; 20% of them are below 40 years old. The optimal management of ET during pregnancy and postpartum periods is still not well established. PATIENT CONCERN: We report a case of a young lady with type 2 calreticulin-mutant ET who developed a marked rebound in her platelet count (reaching 2030 × 103/µL) 2 weeks after premature delivery of her baby (24th week of gestation). She was on Pegylated Interferon alfa 2-a during pregnancy (her platelet was around 500 × 103/µL during the second trimester), but she had stopped it on her own from the 20th week of gestation. DIAGNOSIS: Postpartum rebound of platelet count due to medication non-compliance. INTERVENTION AND OUTCOME: We resumed her regular Pegylated Interferon, and subsequently, her platelet count reduced dramatically within 4 weeks to an acceptable level (684 × 103 /µL). CONCLUSION: The guideline is still not well-established regarding the optimal approach for postpartum rebound of platelet count in patients with ET. It is still unclear if the platelet count will fall spontaneously without intervention after the rebound phase. Further research is required to establish the optimal management of ET during the postpartum phase. This case emphasizes the importance of platelet count follow-up during the postpartum period and outlines our management approach in such cases.

Use of rivaroxaban in sickle cell disease and venous thromboembolism: A case report.

INTRODUCTION: Sickle cell disease (SCD) is a hematological disorder characterized by sickling of red blood cells. Patients are at increased risk of venous thromboembolism. There are no guidelines for the management of venous thromboembolism in sickle cell disease specifically in terms of the anticoagulant of choice. PATIENT CONCERNS: Here, we report a case of a 30-year-old lady with past medical history of sickle cell disease who came with chest pain and shortness of breath. DIAGNOSIS: We found that she has bilateral pulmonary embolism (PE). INTERVENTION: She was started on rivaroxaban. OUTCOME: The patient was followed for 18 months, she did not suffer from recurrence of PE, and she did not develop any complications related to rivaroxaban. CONCLUSION: We concluded that rivaroxaban is effective in treating PE in sicklers and also it is safe.

Fatal native aortic valve fungal endocarditis caused by Aspergillus flavus: A case report.

Fungal endocarditis is a rare condition, specifically in immunocompetent patients. Aspergillus species are the etiology in less than 30% of the cases. Moreover, Aspergillus flavus endocarditis is extremely rare and reported in only 7% of the total Aspergillus endocarditis cases. The most common predisposing factors are immunocompromised state, prosthetic valve, and previous cardiac surgery. In most cases, the diagnosis is delayed and occasionally missed. Prompt medical management combined with early surgical intervention is recommended once the diagnosis is established since the mortality rate is nearly 100% without surgical intervention. We report a rare and fatal case of native aortic valve endocarditis in a 49 years old diabetic patient who presented with fever and abdominal pain, complicated by multiple septic embolizations (splenic infarction, cerebral emboli, and limbs ischemia), and in which A. flavus was confirmed post mortem.

Simultaneous renal infarction and splenic infarction as a possible initial manifestation of COVID-19: A case report.

We recommend testing for SARS-CoV-2 in a patient with an unexplained thromboembolic event, even in the absence of fever or respiratory symptoms.

Enoxaparin-induced bullous hemorrhagic dermatosis at a distant location from the injection site.

Heparin-induced bullous hemorrhagic dermatosis is a benign and self-limited condition. However, it might cause significant patient frustration. Clinicians should be aware of this rare adverse reaction.

Concomitant autoimmune hemolytic anemia and pulmonary embolism associated with mild COVID-19: A case report.

Despite its rarity, AIHA can be associated with COVID-19. It should be suspected in a patient with recent COVID-19 presenting with unexplained anemia.