Chronic Myeloid Leukemia following Exposure to Radioactive Iodine (I131): A Systematic Review.

BACKGROUND: Therapy-related leukemia is a term that describes the occurrence of leukemia following exposure to hematotoxins and radiation to emphasize the difference from leukemia that arises de novo. Many agents and host factors contribute to this entity of leukemias. Therapy-related acute myeloid leukemia has an extensive literature review in contrast to therapy-related chronic myeloid leukemia (t-CML). Radioactive iodine (RAI), an established agent in the management of differentiated thyroid carcinomas, has raised concern due to its possible carcinogenic effects. SUMMARY: In this article, we reviewed all the reports from the 1960s to date related to t-CML following RAI on Google Scholar and PubMed. We have identified 14 reports and found that most reports were for men under the age of 60 years with primary papillary thyroid carcinoma and mixed follicular-papillary thyroid carcinoma who developed t-CML mainly between 4 and 7 years after exposure to varying doses of I131. However, the mean dose was 287.78 millicuries (mCi). It was reported that a statistically significant increase in leukemia following RAI therapy (relative risk of 2.5 for I131 vs. no I131). Also, there was a linear relationship between the cumulative dose of I131 and the risk of leukemia. Doses higher than 100 mCi were associated with a greater risk of developing secondary leukemia, and most of the leukemias developed within the initial 10 years of exposure. The precise mechanism through which RAI provokes leukemia is largely unclear. A few mechanisms have been proposed. KEY MESSAGES: Although the risk for t-CML appears to be low based on current reports and does not represent a contraindication to RAI therapy, it should not be disregarded. We suggest including it in the risk-benefit discussion before initiating this therapy. Long-term follow-up for patients is advisable for those who received doses over 100 mCi with a complete blood count, possibly yearly, for the first 10 years. The new onset of significant leukocytosis post RAI exposure should raise the suspicion for t-CML. Further studies are needed to establish or refute a causal relationship.

Cytarabine-Induced Bradycardia: A Case Report.

Cardiotoxicity is damage to the heart muscle, which affects its function. Chemotherapy is known to cause cardiotoxicity along with many other medications and etiologies. Many chemotherapeutic cocktails are known to be associated with cardiotoxicities, such as taxane and cisplatin. Patients might have arrhythmias, severe bradycardia, cardiomyopathy, and even cardiac arrest, so precautions are taken when such medications are started. This report presents a patient who developed severe symptomatic bradycardia after receiving idarubicin and cytarabine and was managed conservatively, along with a literature review of this entity.

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.

Acute hemolysis and methemoglobinemia secondary to fava beans ingestion in a patient with G6PD deficiency: A case report of a rare co-occurrence.

RATIONALE: Favism is a well-known cause of acute hemolytic anemia. Rarely, methemoglobinemia can also happen because of fava bean ingestion in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Few cases with this co-occurrence have been reported in the literature. PATIENT CONCERNS: We report a case of a 47-year-old patient who presented with jaundice that started 2 days after eating fava beans. DIAGNOSES: Laboratory investigations revealed anemia with evidence of hemolysis (high reticulocytes count, high indirect bilirubin, bite cells in peripheral smear). Blood gases showed high methemoglobin level. Reduced level of G6PD enzyme confirmed the diagnosis of G6PD deficiency. INTERVENTION: The patient was kept on supplemental oxygen. He was counselled to avoid food and drugs that can cause acute hemolysis. OUTCOMES: Oxygen saturation improved gradually. The patient was discharged without any complications after 2 days. LESSONS: Patients with G6PD deficiency can develop both acute hemolytic anemia and methemoglobinemia secondary to fava beans ingestion. These patients should not receive methylene blue to avoid worsening hemolysis.

Aortic arch thrombosis complicated by an embolic stroke in a patient with COVID-19: A case report.

INTRODUCTION: Aortic thrombosis is an uncommon condition with serious embolic complications. COVID-19 is currently recognized to be associated with both venous and arterial thrombosis. However, only a limited number of COVID-19 cases associated with aortic thrombosis have been reported in the literature since the beginning of the pandemic. CASE PRESENTATION: A 66-year-old lady was admitted to our hospital with acute ischemic stroke. Floating aortic arch thrombus was detected incidentally on CT imaging. Interestingly, the patient reported a history of fever and cough and was found to have COVID-19 pneumonia based on nasopharyngeal polymerase chain reaction (PCR) and imaging. The patient received three months of anticoagulant therapy, and repeated imaging study did not reveal any aortic thrombus. CLINICAL DISCUSSION: COVID-19 related aortic thrombosis has been reported chiefly in severe cases. The SARS-CoV-2 can directly infect the endothelium of the vessels, which might explain the occurrence of arterial thrombosis in milder COVID-19 cases with the absence of the hyperinflammatory state. The management guideline for aortic thrombosis is scarce and based only on case reports and series. CONCLUSION: Aortic thrombosis is a devastating condition that can be easily missed without clinical suspicion. Our patient developed acute ischemic stroke, most likely embolic originating from the aortic thrombus. The clinician should consider this condition in any COVID-19 patient presenting with thromboembolic events, such as stroke or acute limb ischemia. Further study is required to explain the pathophysiology of arterial/venous thrombosis in mild-moderate COVID-19 cases.

Ramadan Fasting in a Patient with Chronic Myeloid Leukemia Receiving Nilotinib as Upfront.

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm classically described as triphasic disease: chronic, accelerated, and blast crisis. There are many unmet needs and unanswered questions about CML. Intermittent fasting in patients with CML on tyrosine kinase inhibitors is among these unmet needs. Here we report the effect of intermittent fasting on response to nilotinib as upfront in a 49-year-old female Muslim who fasted during Ramadan and took her medication once instead of twice daily and remained in major molecular response.