Lenalidomide-Induced Diffuse Alveolar Hemorrhage in Patient With Multiple Myeloma.

We present a case of multiple myeloma that was treated with a regimen that included lenalidomide. Lenalidomide, a thalidomide analog, is an immunomodulatory drug created synthetically by changing the chemical makeup of thalidomide to increase efficacy and lessen negative effects. It has been authorized for the treatment of relapsed or resistant multiple myeloma. In the case discussed in this report, the patient's lenalidomide dosage was changed to account for her renal impairment. Regardless of this adjustment of the dose, the patient presented with lung infiltrates, hemoptysis, and fever. Unfortunately, she was diagnosed with diffuse alveolar hemorrhage (DAH) secondary to lenalidomide after excluding other causes of hemoptysis. To the best of our knowledge, we believe this is the first case of DAH reported with lenalidomide in Saudi Arabia, which also discusses the possible therapeutic options for such presentations.

Dengue-Induced Hemophagocytic Lymphohistiocytosis: A Case Report and Literature Review.

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon fatal disease of otherwise normal but hyperactive lymphocytes and histocytes. HLH could be primary (hereditary) or secondary (acquired). Fever, hepatosplenomegaly, lymphadenopathy, and neurologic dysfunction are among the common symptoms of HLH. The diagnosis of HLH is based on clinical and biochemical findings. We report here a case of a patient infected with the dengue virus who developed HLH during hospitalization. A 63-year-old female known case of asthma on inhalers, chronic hepatitis B virus, gastritis on proton pump inhibitors, and hemoglobin H disease presented to the emergency department (ED) with a history of high-grade fever (highest recorded temperature 40° C/ 104° F), which was relieved partially by antipyretics, generalized fatigability, body aches, headache and mosquito bites for four days. The physical examination was significant for hepatomegaly of 4 cm below the right costal margin. Investigations revealed pancytopenia with elevated ferritin levels (> 40000 µg/L). Viral serology was positive for dengue NS1 antigen. After hematology consultation, a bone marrow biopsy was done, which showed trilineage hematopoiesis with increased histiocytes and occasional hemophagocytosis. Given that the patient was clinically stable and there was a clear triggering condition, we opted for supportive measures rather than HLH-specific therapy. The patient was given 2 units packed red blood cells for anemia. On the following days, the patient has no recurrence of fever, with marked improvement in the biochemical profile including ferritin level (1165 µg/L). HLH is a deleterious disease with a high fatality rate, which requires the clinician to have a low threshold for suspicion in the differentials of children and adults with symptoms of persistent fever, hepatosplenomegaly, and cytopenia. Dengue-associated HLH diagnosis is challenging, but it is very important to be recognized, as early recognition is associated with better outcomes. Physicians must work in collaboration with pathologists and microbiologists for the proper diagnosis.

Low-Grade Endometrial Stromal Sarcoma Extending to The Right Atrium.

Endometrial Stromal Sarcoma (ESS) are very uncommon malignant tumors that make around 0.2% of the entire uterine related malignancies. They represent the endometrial stromal cells in the proliferative stage. The annual incidence of ESS is 1-2 per million women. We present an unusual case of ESS, which originates from the uterine artery through the Inferior Vena Cava (IVC) and extends to the right atrium. A 48 years old woman presented with menorrhagia and right flank pain for seven months. Physical examination was normal except for a palpable suprapubic mass. Computed tomography (CT) showed the right gonadal vein and IVC tumoral thrombus extending into the right atrium. An echocardiogram and Transesophygeal echocardiogram revealed a large non-mobile echogenic density in the right atrium. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was done. Extensive myometrial and vascular invasion was noted along with the extensive lymphovascular invasion of the uterus. Eventually, distal IVC resections were done, and there was no chance to remove the tumor because it was too attached and invaded the IVC filter. Owing to the unresectability of the tumor, the patient was assigned for palliative chemotherapy. Keywords: Endometrial Stromal Sarcoma, Right Atrium, Inferior Vena Cava, Spindle Cell Sarcoma.