COVID-19 pandemic and the risk of infection in multiple sclerosis patients on disease modifying therapies: "what the bleep do we know?"

The novel coronavirus which emerged in Wuhan province of China has taken world by surprise. Since been diagnosed in December 2019, it has been termed a "Pandemic" and there is a growing concern in physicians across the globe. As new evidence is emerging, there are various preventative strategies which are being deployed. Multiple sclerosis patients who are on disease modifying therapies (DMTs) might be at a higher risk of acquiring or a poorer outcome due to their immune status. This review looks at the available evidence in managing this global crisis.

Dual Monoclonal Antibody Therapy in Patients With Systemic AL Amyloidosis and Cardiac Involvement.

BACKGROUND: Systemic AL amyloidosis (AL) is a rare disease in which clonal immunoglobulin light chains produced by monoclonal plasma cells circulate and misfold, resulting in direct toxicity and fibrillar deposition of amyloid in numerous tissues. Early mortality from cardiac damage remains high. As depth of organ response carries a prognostic significance, combining anti-plasma cell and anti-amyloid therapies might hold the key to achieving long lasting responses. We report a series of patients who received 2 monoclonal antibodies, anti-CD38 and anti-amyloid, simultaneously. MATERIALS AND METHODS: We describe the characteristics and outcomes of 19 patients who received daratumumab (anti-CD38) on progression with front-line therapy for AL, 9 of whom were on concurrent dual monoclonal antibody treatment with daratumumab and NEOD001 (anti-amyloid), and also provide data on the schedule, safety, and tolerability of intravenous infusions of these monoclonal antibodies. RESULTS: The 9 patients who received treatment with dual monoclonal antibodies achieved a high rate (100%) of hematologic response in a median of 33 days. There was no significant toxicity to dual monoclonal antibody therapy. Seven of the 8 met criteria for cardiac response, achieved in less than 3 months of combined therapy. Ten patients who received daratumumab alone also had high rates of hematologic and organ responses. CONCLUSIONS: Monoclonal antibodies with distinctly different targets can be safely combined in patients with AL and cardiac involvement. Patients experienced high rates of hematologic and cardiac response with combined anti-CD38 and anti-amyloid monoclonal antibody therapies. Further study of this combined approach is warranted.

Nephropleural Fistula Effectively Managed with Serial Thoracentesis: A Case Report.

Nephropleural fistulae are rare but serious thoracic complications of percutaneous nephrolithotomy (PCNL). Herein, we present the management of a 54-year-old female with a delayed presentation of nephropleural fistula. The role of serial thoracentesis as a safe, less invasive, less painful alternative to tube thoracostomy is highlighted. In select cases, this may represent an attractive management strategy for nephropleural fistula after PCNL.

Diffuse Autoimmune Enteropathy and Colopathy in an Adult Patient Successfully Treated With Adalimumab and a Review of the Literature.

Autoimmune enteropathy (AIE) is a rare disease that causes intractable diarrhea not responsive to a gluten free diet and must be distinguished from refractory sprue. It is associated with circulating autoantibodies against goblet cells and enterocytes. AIE mainly involves the small intestines, with very few cases reported in adults. Because of the paucity of cases, the epidemiology of the disease remains unclear, and treatment is based on the cases found in the literature. Of the 35 adult cases reported, only 4 involved the colon. Because of the low number of cases, there have been no clear recommendations on treatment modalities with most reports heavily emphasizing steroids as the mainstay of treatment. We present the case of adult female patient who developed postpartum AIE and colopathy with profuse diarrhea successfully treated with adalimumab and a review of the literature. To the best of our knowledge, this case is only the fourth case of a tumor necrosis factor alpha antagonist being used in the treatment of AIE and the first case of adalimumab being used.

Evaluation and enhancement of medical knowledge competency by monthly tests: a single institution experience.

BACKGROUND: In-training examination (ITE) has been used as a predictor of performance at the American Board of Internal Medicine (ABIM) certifying examination. ITE however may not be an ideal modality as it is held once a year and represents snapshots of performance as compared with a trend. We instituted monthly tests (MTs) to continually assess the performance of trainees throughout their residency. OBJECTIVE: To determine the predictors of ABIM performance and to assess whether the MTs can be used as a tool to predict passing the ABIM examination. METHODS: The MTs, core competencies, and ITE scores were analyzed for a cohort of graduates who appeared for the ABIM examination from 2010 to 2013. Logistic regression was performed to identify the predictors of a successful performance at the ABIM examination. RESULTS: Fifty-one residents appeared for the ABIM examination between 2010 and 2013 with a pass rate of 84%. The MT score for the first year (odds ratio [OR] =1.302, CI =1.004-1.687, P=0.04) and second year (OR =1.125, CI =1.004-1.261, P=0.04) were independent predictors of ABIM performance along with the second-year ITE scores (OR =1.248, CI =1.096-1.420, P=0.001). CONCLUSION: The MT is a valuable tool to predict the performance at the ABIM examination. Not only it helps in the assessment of likelihood of passing the certification examination, it also helps to identify those residents who may require more assistance earlier during their residency. It may also highlight the areas of weakness in program curriculum and guide curriculum development.

Emergent echocardiography and extracorporeal membrane oxygenation: Lifesaving in massive pulmonary embolism.

Massive pulmonary embolism is a life-threatening emergency that results in circulatory failure. The main challenges in management are early diagnosis and maintenance of hemodynamic stability. We present a case of a 63-year-old male who was in cardiac arrest. After resuscitation, massive pulmonary embolism was diagnosed with the help of bedside echocardiography and extracorporeal membrane oxygenation (ECMO). We were able to maintain hemodynamic stability and improve hypoxia until the patient underwent embolectomy. This case demonstrates a common presentation of massive pulmonary embolism highlighting the main challenges in its management and the role of echocardiography and ECMO in improving outcomes in such scenarios.

Non-secretory myeloma: a rare variant of multiple myeloma.

The spectrum of plasma cell neoplasm represents indolent conditions like Monoclonal Gammopathy of Undetermined Significance (MGUS) to more aggressive multiple myeloma and plasma cell leukemia. Non-secretory myeloma comprises less than 01% of this spectrum where serum protein electrophoresis and quantitative immunoglobulins remain essentially normal. We are presenting a case report of this rare variant involving the sternum of an adult male.

Imatinib-related bone marrow aplasia after complete cytogenetic response in chronic myeloid leukemia.

Imatinib mesylate is a BCR-ABL tyrosine kinase inhibitor used in the management of chronic myeloid leukemia. It is a safe and well-tolerated agent with a few manageable side effects. We are reporting a case of imatinib-related fatal bone marrow aplasia after complete cytogenetic response.