ABSTRACT
The incidence of cancer continues to rise, with an estimated 1 in 2 of the UK population born after 1960 diagnosed with malignancy at some point during their lifetime. This is in the context of an ageing population with increasing multimorbidity and polypharmacy. Cancer patients are frequent users of emergency care services and have a high rate of ambulance conveyance and hospital admission after review in emergency departments. Presentations can be a consequence of the cancer, its treatment or coexistent morbidity. Given the expanding armamentarium of cancer therapies, acute and general physicians are faced with a myriad of complex issues and require a knowledge of the broad principles of initial assessment, initial management and timely access to the wider multi-professional cancer team. © 2022
ABSTRACT
The incidence of cancer continues to rise, with an estimated 1 in 2 of the UK population born after 1960 diagnosed with malignancy at some point during their lifetime. This is in the context of an ageing population with increasing multimorbidity and polypharmacy. Cancer patients are frequent users of emergency care services and have a high rate of ambulance conveyance and hospital admission after review in emergency departments. Presentations can be a consequence of the cancer, its treatment or coexistent morbidity. Given the expanding armamentarium of cancer therapies, acute and general physicians are faced with a myriad of complex issues and require a knowledge of the broad principles of initial assessment, initial management and timely access to the wider multi-professional cancer team. Copyright © 2022
ABSTRACT
CASE: The patient is a 66-year-old male presenting with progressive ambulatory dysfunction and lower extremity weakness that began ten days ago. Notably, the patient was admitted to the hospital two months prior with similar complaints. At that time, he was diagnosed with transverse myelitis after MRI showed a spinal cord lesion concerning for demyelination at T3-T4. The patient was treated with IV steroids and discharged. Neurology impression at time of discharge was transverse myelitis possibly related to Covid vaccination two weeks prior to admission. The patient states he was doing fine after initial discharge before recurrence of his progressive weakness and difficulty walking that led to the current admission. He denies fever, chest pain, abdominal pain, and bladder/ bowel incontinence. The patient is a former smoker and denies current alcohol or drug use. Past medical history includes WPW status post ablation, stable thoracic aortic aneurysm, peripheral neuropathy secondary to past alcohol abuse, osteoarthritis, GERD, and anxiety. Family history is remarkable for cancer, coronary artery disease, and diabetes in his father. Medications include metoprolol, tamsulosin, pantoprazole, olanzapine, and venlafaxine. Neurological exam is positive for atrophy and decreased vibratory sensation in bilateral lower extremities. His gait is not assessed due to safety concerns, but the patient notes he has begun using a cane to assist with ambulation. Otherwise, physical exam is unremarkable. Imaging studies include MRI showing T3-T4 hyperintensity, as seen during previous admission two months prior. Labs including ANA, rheumatoid factor, SPEP, CSF studies, and AQP-4 were negative. After an unrevealing workup, the patient experienced symptomatic improvement with IV steroids and was discharged home. IMPACT/DISCUSSION: Our case illustrates a clinical picture of Covid-19 vaccine-related transverse myelitis, a rare but serious complication of the vaccine. The prolonged course of this patient's complications is concerning, although the benefit of receiving the vaccine remains unquestionable. Furthermore, although the timing of symptom onset and vaccination suggests a relation, there are other diagnoses that could explain the presentation and further research is needed regarding vaccine-related side effects. This case emphasizes the importance of maintaining a high index of suspicion for neurological issues of unclear etiology following recent Covid-19 vaccination despite their rare occurrence. CONCLUSION: Teaching points: Diagnostic criteria for transverse myelitis includes sensory, motor, or autonomic dysfunction attributable to spinal cord, no evidence of cord compression, bilateral symptoms with clear sensory level, and inflammation defined by CSF analysis, elevated IgG, or MRI enhancement. Neurological complications of the Covid vaccine include general symptoms such as headache, fever, and fatigue, Bell's palsy, encephalomyelitis, myelitis, and cerebral venous sinus thrombosis.
ABSTRACT
CASE: A 78-year-old female with a history of recurrent nephrolithiasis and left ureteral reconstruction presented to our institution with hematuria, flank pain, anorexia and weight loss. 3-4 months prior, she had similar symptoms in her home country and was treated with multiple courses of antibiotics. She attempted to present to the US for evaluation earlier, but was unable to due to COVID. She first presented to a nearby US hospital and was diagnosed with an atrophic kidney with a superimposed infection based on imaging and labs. An EGD/ Colonoscopy done for her weight loss was unrevealing. She was discharged on antibiotics and told to follow up for possible nephrectomy. 1 days later, she presented to our institution with continued symptoms. Repeat CT was concerning for emphysematous pyelonephritis. Vital signs were unremarkable. Labs showed no leukocytosis, normal creatinine, hypercalcemia to 13.0 and urinalysis showed hematuria, pyuria and proteinuria. She was initially treated with IV antibiotics and a percutaneous nephrostomy for source control. To continue work up for her weight loss, a CT chest was done that showed multiple lung nodules and a re-review of the CT abdomen noted a T12 lytic lesion. 2 weeks into her admission, she had a left nephrectomy. Pathology revealed an invasive, grade 3, poorly differentiated squamous cell carcinoma arising from the renal pelvis, with lymphovascular invasion. A biopsy of the T12 lesion was consistent with metastasis. Due to her functional status and aggressive nature of her malignancy, palliative therapies were recommended. Patient's course was further complicated by ileus, massive aspiration and spinal cord compression from the T12 lesion. She passed away on hospital day 45. IMPACT/DISCUSSION: Squamous cell carcinoma of the renal pelvis is a rare malignancy. Most present at an advanced stage with a long history of nonspecific symptoms, such as hematuria and/or flank pain, which are typically attributed to recurrent nephrolithiasis;one of the most well-documented risk factors. Additionally, there are no characteristic findings on imaging, making radiological differentiation between renal SCC and other chronic infectious processes difficult. Often there is no suspicion for malignancy until the pathology results. For these reasons, renal SCC should be considered in patients who have underlying risk factors. One may also benefit from a renal biopsy, which can be done before a nephrectomy and has been shown to have a high degree of diagnostic accuracy. Adding to this diagnostic challenge, our patient's care was delayed due to COVID, demonstrating the importance of considering alternative diagnoses when patients have deferred presentations and fractured workups. CONCLUSION: Consider the diagnosis of renal SCC in patients with recurrent nephrolithiasis, UTIs, unexplained hematuria and/or flank pain and refer for a renal biopsy if appropriate. Be mindful of the impact of fragmented and delayed medical care on vulnerable patients.
ABSTRACT
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has been associated with a plethora of symptoms weeks after the acute infection. While many reports have investigated the novel syndrome of post-acute sequelae of COVID-19, fewer studies have examined post-COVID-19 secondary infections, which may be distinct from typical post-viral bacterial infections due to the multiorgan involvement of COVID-19. This case report aims to highlight a presentation in which a 65-year-old man had COVID-19 and subsequently developed methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia with widespread seeding of secondary infections, including abscesses in the hand and paravertebral regions as well as discitis/osteomyelitis of the cervical spine. Further studies are needed to investigate whether an increased susceptibility to unusual secondary bacterial infections is present in post-COVID-19 patients.
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Background/aims: Radiotherapy is an effective palliative treatment for metastatic disease. The current COVID-19 pandemic has led us to consider shorter courses, new guidelines and prioritize cases clinically urgent. The purpose of this study is to analyze our practice in palliative treatment, new potential strategies and hypofractionation. Methods: 252 patients who receive palliative radiation treatment from March 2020 to March 2021 were reviewed. We analyze how the treatment line has been modified throughout the 1 year of the pandemic and other items related to the different therapeutic options as mortality, reirradiation, primary localization and intention. Results: Median age was 68 years (range 33-95y), 66% males, 34% females. Main primary tumors were 30% lung, 12% prostate and 10% breast. 65% patients had painful bone metastases, 15% brain metastases, 14% cord compression, 4% bleeding and 2% superior vena cava obstruction. Advanced disease was detected in 12% as debut. Half of patients were treated in the two first months of the pandemic than later. Treatment provided was: 8 patients required reirradiation. Currently, 66% died. Conclusions: Radiotherapy plays a critical role improving quality of life in patients with advanced disease, even in the midst of the COVID-19 pandemic. During the first months of confinement, short radiation therapy cycles prevailed over the long ones, as the normal schemes of fractionation coinciding with a greater number of sessions gained importance as time went on. (Table Presented).
ABSTRACT
Background/aims: Many reports have described pain appearance or an increase of chronic pain concomitant to SARS-CoV-2 infection. Here, we describe the cases of three patients with chronic cancer pain, in which COVID-19 was associated with a dramatic reduction/disappearance of pain. Methods: Descriptive report of three oncological patients with chronic pain hospitalized in the contexte of acute COVID-19. Clinical information was personally retrieved by the authors, who also examined the patients. Brain MRI was performed when deemed necessary by the referring physician. Autopsy, when conducted, was performed at the request of family members. All three patients were hospitalized between October 2020 and January 2021 Results: In this case series we describe, for the first time, a group of patients with chronic oncological pain, in which severe SARS-CoV-2 infection resulted in a temporary decrease of pain perception. It should be noted that despite optimal treatment, pain was insufficiently controlled in all cases prior to the infection. Patient 1 suffered from medullary compression at D2 due to probable perivertebral metastasis associated with bone lysis;patient 2 suffered from painful rib metastases;patient 3 suffered from neoplastic infiltration of the rectum from a bladder adenocarcinoma. None of the patients had impaired cognitive function that could have compromised their evaluation of pain. None of the patients complained of dyspnea at the moment of hospitalization;moreover, the reappearance of pain in patient 3 coincided with recovery from COVID-19 and de novo onset of dyspnea. Conclusions: To our knowledge, thisis the first case series reporting an acute reduction in pain perception in COVID-19. We believe further investigation is mandatory, as it could shed new light on the mechanisms of pain perception and modulation.
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Introduction Throughout the COVID-19 pandemic, our understanding of the relationship between COVID-19 infection and acute neurological disorders has been evolving. We present two cases of trans-verse myelitis, both with positive COVID-19 PCRs. Case 1: A 62-year old man presented with an ascending paraparesis 3 weeks after COVID-19 infection. Initial neuroimaging showed cord compression with signal change at C5/6. Repeat imaging 7 days later showed a longitudinal myelitis. CSF examination was unremarkable. He was treated with intravenous steroids and an oral taper. No other cause was identified. Case 2: A 55-year old woman presented with sub-acute back pain and worsening leg weakness over 2 weeks. She had a positive COVID-19 test on admission but was asymptomatic. Neuroimaging showed a longitudinal myelitis, but also noted a multicystic lesion within the pelvis. A CSF examination was unremark-able with negative cytology. A raised CA-125 coupled with an adnexal mass on CT-TAP was felt in keeping with ovarian malignancy which we hypothesise caused the myelitis through an immune phenomena, rather than by a para-infectious route or by COVID-19 itself. Conclusions These cases highlight the broad aetiology of transverse myelitis and illustrate the need for a careful search for underlying causes, which may include post-COVID syndromes.
ABSTRACT
Background: Bone loss is a well-recognised complication of myeloma, affecting up to 90% of patients. It is associated with fractures, spinal cord compression and hypercalcaemia. 1,2 Myeloma patients are routinely prescribed zoledronic acid, which has been shown to prevent skeletal-related events, preserve bone density and prolong progression-free survival.3 At NBT, zoledronic acid is prescribed on a paper prescription chart, which is not routinely reviewed by a pharmacist This process is not in accordance with other therapy, which is prescribed on ChemoCare and clinically verified by a pharmacist prior to administration. Objectives • To assess the adherence of zoledronic acid prescribing at NBT against the South West Clinical Network (SWCN) protocol. • To identify areas for improvement in the prescribing of zoledronic acid for prevention of skeletal events. Standards: 100% of patients receiving zoledronic treatment should meet the following go-ahead criteria:4 • Acceptable bloods within seven days of treatment (creatinine, calcium, phosphate, magnesium) • Comprehensive dental examination. • Dose modification based on creatinine clearance. • Treatment deferred if hypocalcaemia or hypophosphataemia. Methodology: The audit was conducted over a one month period between 1/11/2020 and 30/11/2020. A total number of 58 prescriptions were included in the audit. The data collection sheet for the audit included;patient details, date of treatment and zoledronic acid dose. This information was extracted from the drug charts. The information system ICE was used to verify the blood results and validity period. Creatinine clearance was calculated using the Cockcroft and Gault equation. The medical notes were reviewed for evidence of dental checks. Data was recorded on Excel for further analysis by the pharmacist. Results: An overview of all four audit standards is shown in Figure 1. Two of the four audit standards were fully met (standards 2 and 4). 2% of patients (n= 1/58) did not receive an appropriate zoledronic acid dose adjustment based on renal function (standard 3). 36% (n=21/58) of patients did not have bloods within seven days of treatment (standard 1), however all of these patients had bloods within a month of treatment, in line with the Summary of Product Characteristic recommendations.5 Discussion and conclusion: The audit demonstrated that adherence to zoledronic acid prescribing guidelines is generally satisfactory;however several areas for improvement were identified. Feedback was provided to the haematology team and the following recommendations made: • Critical bloods must be done within one week of treatment. • Evidence of a dental examination must be clearly documented. • An approved app must be used for calculating creatinine clearance. • Introduction of a pharmacist clinical verification. • Zoledronic acid should be prescribed on ChemoCare, to assist with the above recommendations. Limitations: This audit was only carried out over a month which will only provide a snapshot of prescribing and results may have been impacted by the COVID-19 pandemic. It was difficult to find documentation for dental checks and treatment delays due to bloods and in some cases, information had to be verified by the prescriber.
ABSTRACT
Tuberculosis (TB) is a communicable, airborne infectious disease caused by the bacterium Mycobacterium tuberculosis (MTB). A quarter of the world's population is infected with TB, affecting all age groups. Infection with MTB results in latent or active disease. Latent infection is associated with a 10% lifetime risk of developing active disease, but this is much higher in those with concurrent immunosuppression. Despite being both preventable and curable, TB remains the leading cause of global death from a single infectious agent. Active disease most commonly affects the lungs but can spread to cause extrapulmonary disease anywhere in the body. Over half of individuals in the UK now present with features of extrapulmonary TB, those with HIV being at particular risk. In all cases, obtaining samples for TB culture is absolutely vital. Standard treatment is with quadruple therapy for 6 months, extended in TB meningitis and often TB bone infection. Adjunctive corticosteroids have proven benefit in TB meningitis and TB pericarditis, and can be considered in other circumstances, such as paradoxical reactions to starting treatment in miliary TB. Despite recent gains in diagnosing and treating TB cases worldwide, the global COVID-19 pandemic is likely to have significantly affected recent progress.