Optimizing Inpatient Care for Lung Cancer Patients with Immune Checkpoint Inhibitor- Related Pneumonitis Using a Clinical Care Pathway Algorithm.

Purpose: Immune checkpoint inhibitor-related pneumonitis (ICI-P) is a condition associated with high mortality, necessitating prompt recognition and treatment initiation. This study aimed to assess the impact of implementing a clinical care pathway algorithm on reducing the time to treatment for ICI-P. Methods: Patients with lung cancer and suspected ICI-P were enrolled, and a multi-modal intervention promoting algorithm use was implemented in two phases. Pre- and post-intervention analyses were conducted to evaluate the primary outcome of time from ICI-P diagnosis to treatment initiation. Results: Of the 82 patients admitted with suspected ICI-P, 73.17% were confirmed to have ICI-P, predominantly associated with non-small cell lung cancer (91.67%) and stage IV disease (95%). Pembrolizumab was the most commonly used immune checkpoint inhibitor (55%). The mean times to treatment were 2.37 days in the pre-intervention phase and, 3.07 days (p=0.46), and 1.27 days (p=0.40) in the post-intervention phases 1 and 2, respectively. Utilization of the immunotoxicity order set significantly increased from 0% to 27.27% (p = 0.04) after phase 2. While there were no significant changes in ICU admissions or inpatient mortality, outpatient pulmonology follow-ups increased statistically significantly, demonstrating enhanced continuity of care. The overall mortality for patients with ICI-P was 22%, underscoring the urgency of optimizing management strategies. Notably, all patients discharged on high-dose corticosteroids received appropriate gastrointestinal prophylaxis and prophylaxis against Pneumocystis jirovecii pneumonia infections at the end of phase 2. Conclusion: Implementing a clinical care pathway algorithm for ICI-P management standardizes care practices and enhances patient outcomes, underscoring the importance of structured approaches.

Hemophagocytic Lymphohistiocytosis Secondary to Immune Checkpoint Inhibitor Therapy.

Hemophagocytic lymphohistiocytosis (HLH) is a fatal systemic inflammatory syndrome. HLH has been reported as a rare immune-related adverse event (irAE) in patients receiving immunotherapy with nivolumab, ipilimumab, and/or pembrolizumab. The data are limited to case reports and case series. The objective of this research is to compile data on this rare but potentially life-threatening adverse event of immune checkpoint inhibitors (ICIs) and identify the common agents that cause this irAE, clinical spectrum, and successful management strategies to assist the treating oncologists. A review was done using PubMed database. Eligible articles included case reports and case series published from January 1, 2015, through February 1, 2021. Reports published in languages other than English were excluded. Data were compiled into a detailed supplementary table and simple descriptive analysis was used to interpret data. A total of 22 cases were included, which constituted 14 individual case reports and two case series. The immunotherapy prescribed consisted of antibodies against and programmed cell death 1 (PD-1) or its ligand, programmed cell death ligand 1 (PD-L1) in all 22 patients. Out of them, immunotherapy consisting of anti-cytotoxic T-lymphocyte antigen 4 (anti-CTLA-4) antibodies was prescribed in nine patients. Fever was the most common symptom at the presentation (90.9%). The most common laboratory findings were anemia (90.9%), thrombocytopenia (90.9%), and elevated ferritin (90.9%). All the patients received steroids (100%). HLH responded to treatment in 19 patients. Three patients died. Three patients were rechallenged with immunotherapy, with no recurrence of HLH. HLH in the setting of ICI therapy is life-threatening, but potentially treatable with early detection. However, diagnosis is often delayed due to difficulty in differentiating the presenting symptoms and laboratory findings from complications of cancer and other therapies. Majority have shown an adequate response to standard HLH treatment; however, some required a longer course of corticosteroids. HLH is not always associated with other irAE. Rechallenging with immunotherapy was successful in some patients after completing treatment for HLH.

Invasive Fungal Infection Complicating Treatment With Ibrutinib.

Ibrutinib is a selective Bruton's tyrosine kinase inhibitor (BTKi) approved for the treatment of chronic lymphocytic leukemia (CLL) and other B-cell malignancies. Invasive fungal infections (IFIs) have recently been reported in patients on BTKis despite the absence of significant immunocompromise raising great interest among oncologists regarding the mechanism by which BTKi's permit fungal infections. Here, we describe a fatal case of cerebral aspergillosis in a patient with relapsed CLL while on treatment with ibrutinib. There are few hypotheses on the mechanism by which ibrutinib permits fungal infections. As it becomes more widely used in B-cell cancers, clinicians should be aware of the potential for decreased anti-fungal immunity with this drug.

Autoimmune Hemolytic Anemia Associated With Human Babesiosis.

Babesiosis is characterized by non-autoimmune hemolytic anemia as a result of invasion of red blood cells by intraerythrocytic protozoans. Upon evaluation of patients who have ongoing hemolysis despite antibiotic treatment, a new entity of autoimmune hemolytic anemia (AIHA) was recently identified in some patients with babesiosis. The data are limited to case reports and one case series. The aim of this research was to synthetize data on this topic according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database. In this review, we found that all patients who had developed AIHA were asplenic. All had Coombs test positive for IgG or both IgG and C3 indicating Warm AIHA. Some but not all required blood transfusion and plasma exchange. Majority of patients responded to steroids and had resolution of parasitemia on follow-up. We believe that this review will make the clinicians aware that babesiosis can not only cause non-immune hemolysis but also AIHA. It is important to differentiate between the two entities as antibiotics alone may not be sufficient for immune-mediated hemolysis caused by babesiosis.

An Update on Survivorship Issues in Lung Cancer Patients.

Recent advances in lung cancer therapeutics and screening have led to increased numbers of lung cancer survivors. Most survivors have undergone invasive treatment (surgery, radiation therapy, chemotherapy and/or immunotherapy) and carry a high comorbidity burden. Overall quality of life suffers during the evaluation, treatment and follow-up phase, with the potential for long-term decline. The issues faced by survivors include physical symptoms, emotional distress as well as socioeconomic instability. These issues may lead to poor compliance with recommended follow-up plan. This article provides an up-to-date literature review on the major issues faced by lung cancer survivors and identifies under-recognized problems such as stigma, financial toxicity and sexual dysfunction. Future collaborative efforts are needed to further elucidate the complex issues that affect overall well-being of lung cancer survivors and to develop appropriate interventions in this expanding survivor population.

Hemophagocytic Lymphohistiocytosis Secondary to Prostatic Adenocarcinoma.

Hemophagocytic lymphohistiocytosis (HLH) is caused by excessive immune activation. It can be primary in the setting of genetic defects or secondary in the setting of infection, inflammation, and malignancy. Here we present the fourth reported case of secondary HLH in association with prostatic adenocarcinoma and the diagnostic challenges of this rare, life-threatening condition. This is a 78-year-old male who presented to the hospital with fever and generalized weakness for three days and found to have splenomegaly, pancytopenia, markedly elevated transaminases, and ferritin. Bone marrow biopsy revealed hemophagocytes. He underwent an extensive evaluation to identify the etiology. Para-aortic lymph node biopsy was consistent with prostatic adenocarcinoma. The diagnosis of HLH needs a high index of suspicion because the presentation is nonspecific. HLH is a rapidly progressive and potentially fatal condition underscoring the need for a prompt evaluation if this condition is suspected.

A matched cohort study of convalescent plasma therapy for COVID-19.

INTRODUCTION: COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a public health crisis. Prior studies demonstrated successful use of convalescent plasma therapy for treatment of other viral illnesses. Our primary objective was to evaluate treatment efficacy of convalescent plasma in patients with COVID-19. MATERIALS AND METHODS: In this retrospective matched cohort study, we enrolled recipients of convalescent plasma collected from donors recovered from laboratory-confirmed SARS-CoV-2 infection under the single patient eIND process. We individually matched 35 cases with 61 controls based on age, gender, supplemental oxygen requirements, and C-reactive protein level at the time of hospital admission. We compared the outcomes of in-hospital mortality and hospital length of stay between the groups. RESULTS: In-hospital mortality was 20% among the cases and 24.6% among the controls (P = .61). A multivariable logistic regression model that included age, gender, duration of symptoms, need for mechanical ventilation, and pharmacologic interventions revealed no significant difference in mortality by study group (P = .71). The median length of stay was significantly greater among convalescent plasma recipients compared with controls, 10 (IQR, 6-17) vs 7 (IQR, 4-11) days, P < .01. The difference was not significant after controlling for covariates (P > .1). CONCLUSIONS: We did not find convalescent plasma reduced in-hospital mortality in our sample, nor did it reduce length of stay. Further investigation is warranted to determine the efficacy of this treatment in patients with COVID-19, particularly early in the disease process.

Anaplastic Large Cell Lymphoma Masquerading as Submandibular Sialolithiasis.

Anaplastic large cell lymphoma (ALCL) is an aggressive neoplasm of T- or null cell phenotype. It is rarely associated with a leukemic phase. Based on a structured literature review, salivary duct obstruction and sialolithiasis have not been reported as a presenting feature of lymphoma. Here, we report a case of a 74-year-old male who was initially referred to an otolaryngologist for sialolithiasis and was later found to have a rare and aggressive form of lymphoma on further evaluation. He was diagnosed with anaplastic lymphoma kinase (ALK) positive anaplastic large cell lymphoma with a leukemic phase complicated by multiorgan failure and tumor lysis syndrome, leading to death prior to the initiation of chemotherapy. The aim of this report is to make clinicians aware of this unusual presentation, as early recognition and timely referral to the appropriate specialist is important to prevent adverse outcomes. This also emphasizes the importance of exploring the underlying etiology of disease in addition to treating the disease itself, as presenting symptoms can mask the underlying etiology.