Immune Effector Cell-Associated HLH-like Syndrome: A Review of the Literature of an Increasingly Recognized Entity.

Since CAR-T cell therapy was initially approved in 2017, its use has become more prevalent and so have its side effects. CAR-T-related HLH, also named immune effector cell-associated HLH-like syndrome (IEC-HS), is a rare but fatal toxicity if not recognized promptly. We conducted a review of the literature in order to understand the prevalence of IEC-HS as well as clarify the evolution of the diagnostic criteria and treatment recommendations. IEC-HS occurrence varies between CAR-T cell products and the type of malignancy treated. Diagnosis can be challenging as there are no standardized diagnostic criteria, and its clinical features can overlap with cytokine release syndrome and active hematological disease. Suggested treatment strategies have been extrapolated from prior experience in HLH and include anakinra, corticosteroids and ruxolitinib. IEC-HS is a potentially fatal toxicity associated with CAR-T cell therapy. Early recognition with reliable diagnostic criteria and prompt implementation of treatment specific to IEC-HS is imperative for improving patient outcomes.

Scurvy in the Modern World: Extinct or Not?

Scurvy is a nutritional disorder caused by vitamin C deficiency. It was a notorious disease in the ancient world, especially among the sailors, and is of rare occurrence in contemporary, developed countries due to increased access and advancement in nutrition services. Scurvy primarily affects the skin and soft tissue, presenting with a myriad of clinical manifestations ranging from musculoskeletal to bleeding-related complaints and even sudden death in later stages. In this article, we present the case of an elderly female with scurvy-related weakness and gait instability leading to mechanical falls, easy bruising, fatigue, and petechial rash. She had improvement in her constitutional symptoms after the initiation of vitamin C supplements. This case reinforces the need to consider scurvy as one of the differentials for petechial rash and easy bruising apart from bleeding diathesis and vasculitis in the contemporary world, especially in at-risk populations.

Alpelisib-Induced Diabetic Ketoacidosis in a Non-diabetic Patient.

Alpelisib is a phosphoinositol-3-kinase alpha catalytic subunit (PIK3CA) inhibitor used in patients with PIK3CA mutated breast cancer. The phosphatidylinositol 3-kinase (PI3K) pathway is responsible for activating protein kinase-B (AKT), and activated AKT promotes translation of glucose transporter 4 and glycogen synthesis in insulin-responsive tissues. Therefore, it is perhaps not surprising that hyperglycemia is the most common side effect of alpelisib, though diabetic ketoacidosis (DKA) appears to be a rare complication. This case describes the unique presentation of a patient with no prior history of diabetes who presented with DKA after starting alpelisib, and returned to euglycemia off of insulin just three days after stopping the drug suggesting that alpelisib can cause DKA in patients who did not previously have diabetes, and that the hyperglycemia is completely reversible upon discontinuation of the PIK3CA inhibitor and consequent restoration of the PI3K/AKT pathway.

Chryseobacterium gleum Causing Healthcare-Associated Pneumonia in an Adult Male With Diffuse Large B Cell Lymphoma.

Chryseobacterium species are recognized as an emerging opportunistic bacterial pathogen in nosocomial settings especially in debilitated or immunosuppressed patients and neonates. The ubiquitous distribution in nature, ability to form biofilms with inherent resistance to broad-spectrum antimicrobials, and lack of clinical studies pose a further diagnostic and therapeutic challenge. This case report describes an elderly male with relapsed diffuse large B-cell lymphoma (DLBCL) status post-chemotherapy and radiation who acquired healthcare-associated pneumonia with sputum isolates showing Chryseobacterium gleum and Stenotrophomonas maltophila. It also includes a review of literature compiling all the previously reported cases with antibiotic susceptibilities, clinical picture, and treatment outcomes.

Classic hairy cell leukemia with an aggressive presentation.

Hairy cell leukemia is an indolent neoplasm involving mature B cells with distinct cytologic and immunophenotypic features. It typically presents in older adults with pancytopenia and splenomegaly. We describe a patient who presented with severe anemia and thrombocytopenia, leukocytosis, and splenomegaly. He had an unusually complicated clinical course including pancytopenia refractory to multiple transfusions, oropharyngeal bleeding requiring intubation for airway protection, subdural hematoma after minor trauma, and sepsis due to Staphylococcus aureus bacteremia. This case highlights the importance of considering hairy cell leukemia in the differential diagnosis of all patients with cytopenia and splenomegaly, as this is a disease that has excellent response to treatment with purine analogs.

Practical Vitamin D Supplementation Using Machine Learning.

BACKGROUND: Patients with breast cancer are at increased risk of developing osteoporosis. Maintaining normal levels of vitamin D may decrease the risk of osteoporosis, and vitamin D levels must be corrected in patients who develop osteoporosis before beginning bone modifying agents. Therefore, it is important to correct insufficient vitamin D levels in a timely manner. In clinical practice, current guidelines for replacement regimens often fail to rapidly correct vitamin D levels. The goal of this study was to review data in order to predict what replacement regimen(s) were most effective at repleting vitamin D levels. METHODS: For this retrospective cohort study, data was collected from medical records of 2,164 female patients with breast cancer with Institutional Review Board approval. Total level change per week was the primary outcome and was compared for the most commonly used vitamin D replacement regimens adjusted for age, race, body mass index, creatinine clearance, endocrine therapy, and initial level. RESULTS: Higher weekly doses of vitamin D supplementation had a more significant impact on the rate of correction compared to lower daily doses. Generalized linear model was used to develop an online calculator that predicts time to vitamin D level correction adjusted for significant patient characteristics for 5 common replacement regimens as well as no intervention. CONCLUSIONS: When choosing a vitamin D replacement regimen for patients with vitamin D deficiency, we recommend clinicians use the online calculator to ensure that the chosen regimen will enable the patient to reach vitamin D sufficiency in a timely manner.