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Holloway A, Ahmed S, Manson JJ. Does your unwell patient have haemophagocytic lymphohistiocytosis? Br J Hosp Med (Lond) 2024; 85:1-12. [PMID: 38557089 DOI: 10.12968/hmed.2023.0394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Haemophagocytic lymphohistiocytosis is a severe systemic hyperinflammatory syndrome characterised by dysregulation of immune cells and excessive production of cytokines, also known as a cytokine storm. It has distinctive clinical features with fever, hyperferritinaemia and falling blood counts. In adults, this usually occurs secondary to an underlying driver or trigger including infection, malignancy or rheumatic diseases. Prompt treatment with immunomodulatory therapy, including corticosteroids and the recombinant IL-1 receptor antagonist anakinra, is recommended to switch off the cytokine storm. Etoposide-based regimens are sometimes needed, and newer therapies such as emapalumab and JAK inhibitors are increasingly being used. The incidence of haemophagocytic lymphohistiocytosis has increased significantly over the last 20 years which may partly reflect increased awareness of the condition. Although relatively rare, haemophagocytic lymphohistiocytosis can be encountered by a broad range of hospital physicians, so knowing how to diagnose and treat this condition is essential. This article reviews the pathogenesis, clinical features, causes, diagnosis and treatment of haemophagocytic lymphohistiocytosis to improve physician recognition and management of this condition to improve future patient outcomes.
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Affiliation(s)
- Amelia Holloway
- Department of Rheumatology, Kings College Hospital, London, UK
| | - Saad Ahmed
- Department of Rheumatology, Addenbrookes Hospital, Cambridge, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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2
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Richardson-May J, Musa AM, Suresh P, Sniatecki JJ, Krishnan R. Leukaemic Optic Neuropathy in a Patient with Treated Acute Lymphoblastic Leukaemia: Optical Coherence Tomography as an Aid to Diagnosis. Neuroophthalmology 2024; 48:352-359. [PMID: 39145319 PMCID: PMC11321405 DOI: 10.1080/01658107.2024.2313579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 08/16/2024] Open
Abstract
Leukaemic optic neuropathy is an uncommon cause of visual loss which represents a neuro-oncological emergency with the potential of irreversible blindness if untreated. It can be difficult to diagnose, often presenting with normal neuroradiological and cerebrospinal fluid findings. We present the case of a 26-year-old woman with T-cell acute lymphoblastic leukaemia with optic neuropathy secondary to leukaemic infiltration, who demonstrated features on optical coherence tomography that aided the diagnosis of this condition. This included the presence of numerous, small, hyperreflective opacities erupting from the optic nerve head, which improved following treatment with radiotherapy and chemotherapy, and later recurred when the condition relapsed. This finding may help clinicians differentiate between other causes of optic neuropathy as well as assessing response to treatment and monitoring for recurrence.
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Affiliation(s)
| | - Abdi M. Musa
- Department of Ophthalmology, University Hospital Southampton, Hampshire, UK
| | | | - Jan J. Sniatecki
- Department of Ophthalmology, University Hospital Southampton, Hampshire, UK
| | - Radhika Krishnan
- Department of Ophthalmology, University Hospital Southampton, Hampshire, UK
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Gahagen RE, Gaylord WC, Drayton Jackson MD, McCallister AE, Lutfi R, Belsky JA. Implementation of an Anterior Mediastinal Mass Pathway to Improve Time to Biopsy and Multidisciplinary Communication. Pediatr Qual Saf 2024; 9:e715. [PMID: 38322297 PMCID: PMC10843474 DOI: 10.1097/pq9.0000000000000715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/09/2024] [Indexed: 02/08/2024] Open
Abstract
Background Mediastinal masses in children with cancer present unique challenges, including the risk of respiratory and hemodynamic compromise due to the complex anatomy of the mediastinum. Multidisciplinary communication is often a challenge in the management of these patients. After a series of patients with mediastinal masses were admitted to Riley Hospital for Children Pediatric Intensive Care Unit, the time from presentation to biopsy and pathology was greater than expected. We aimed to reduce the time to biopsy by 25% and demonstrate improved multidisciplinary communication within 6 months of protocol implementation for patients presenting to Riley Hospital for Children Emergency Department with an anterior mediastinal mass. Methods Quality improvement methodology created a pathway that included early multidisciplinary communication. The pathway includes communication between the emergency department and multiple surgical and medical teams via a HIPPA-compliant texting platform. Based on patient stability, imaging findings, and sedation risks, the approach and timing of the biopsy were determined. Results The pathway has been used 20 times to date. We successfully reduced the time to biopsy by 38%, from 25.1 hours to 15.4 hours. There was no statistically significant reduction in time to pathology. The multidisciplinary team reported improved communication from a baseline Likert score of 3.24 to 4. Conclusions By initiating early multidisciplinary communication, we reduced the time to biopsy and pathology results, improving care for our patients presenting with anterior mediastinal masses.
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Affiliation(s)
- Rachel E. Gahagen
- From the Division of Pediatric Critical Care Riley Hospital for Children
- Department of Pediatrics, Indiana University School of Medicine
| | - William C. Gaylord
- From the Division of Pediatric Critical Care Riley Hospital for Children
- Division of Pediatric Hematology-Oncology Riley Hospital for Children
| | - Meghan D. Drayton Jackson
- From the Division of Pediatric Critical Care Riley Hospital for Children
- Division of Pediatric Hematology-Oncology Riley Hospital for Children
| | | | - Riad Lutfi
- From the Division of Pediatric Critical Care Riley Hospital for Children
- Department of Pediatrics, Indiana University School of Medicine
| | - Jennifer A. Belsky
- From the Division of Pediatric Critical Care Riley Hospital for Children
- Division of Pediatric Hematology-Oncology Riley Hospital for Children
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4
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR Points to Consider at the Early Stages of Diagnosis and Management of Suspected Haemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS). Arthritis Rheumatol 2023; 75:1714-1732. [PMID: 37486733 PMCID: PMC11040593 DOI: 10.1002/art.42636] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, NIH, Bethesda, Maryland
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, and Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Hines
- Pediatric Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University and Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children’s Hospital, Houston
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Edward M. Behrens
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham
| | - Jeffrey I. Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | - Randy Q. Cron
- Pediatric Rheumatology, University of Alabama at Birmingham
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California
| | - Alexei A. Grom
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Lauren A. Henderson
- Pediatric Immunology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Annacarin Horne
- Department of Women’s and Children’s Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B. Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Kim E. Nichols
- Division of Cancer Predisposition Department of Oncology, St. Jude Children’s Research Hospital Department of Oncology, Memphis, Tennessee
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | | | | | - Rebecca A. Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Scott W. Canna
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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5
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR points to consider at the early stages of diagnosis and management of suspected haemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS). Ann Rheum Dis 2023; 82:1271-1285. [PMID: 37487610 PMCID: PMC11017727 DOI: 10.1136/ard-2023-224123] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/27/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Melissa Hines
- Pediatric Critical Care Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children's Hospital, Houston, Texas, USA
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Randy Q Cron
- Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California, USA
| | - Alexei A Grom
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Lauren A Henderson
- Pediatric Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Annacarin Horne
- Department of Women's and Children's Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Kim E Nichols
- Division of Cancer Predisposition Department of Oncology, St Jude Children's Research Hospital Department of Oncology, Memphis, Tennessee, USA
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Rebecca A Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Scott W Canna
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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6
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Shen JZ, Callaway K, Korf B, Rodriguez JM, Gaffo A. Empiric treatment for persistent fever from suspected autoinflammatory disease: Experience from an undiagnosed diseases program. Am J Med Sci 2023; 366:71-75. [PMID: 37062430 DOI: 10.1016/j.amjms.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 03/05/2023] [Accepted: 04/05/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Patients with persistent fevers of undetermined etiology often undergo extensive evaluation without a diagnosis. Autoinflammatory syndromes may not always be considered in the differential, as these are rare entities, there are no consensus clinical criteria and genetic testing can only capture a few of these diseases. We aimed to describe the experience and value of an undiagnosed diseases program in the evaluation and management of patients who present with persistent fevers. METHODS A retrospective analysis was performed on eleven patients who presented with persistent fevers to the Undiagnosed Diseases Program (UDP) at University of Alabama at Birmingham. All patients received extensive testing prior to referral and were seen by multiple subspecialists. The primary outcome of complete remission was resolution of episodes of fever and malaise in response to empiric biological anti-inflammatory treatment. RESULTS All patients received genetic testing and further diagnostic evaluation by the UDP. Even without confirmed genetic testing, they were empirically started on anti-inflammatory therapies (including colchicine, IL-1 inhibitors, IL-6 inhibitors). Ten patients have achieved complete remission on empiric treatment. Three patients were given formal diagnoses. No patients have had any major adverse events from therapy. CONCLUSIONS This is a pilot study suggesting the role for empiric treatment trials of biologics for patients with suspected autoinflammatory diseases. As the differential diagnosis of patients with persistent fevers is broad, and the diagnosis of autoinflammatory diseases often comes with some degree of uncertainty, evaluation by a center with expertise in diagnosing these conditions can help determine which patients should have empiric trials of biologics.
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Affiliation(s)
- Jeffrey Z Shen
- Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Kaitlin Callaway
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Bruce Korf
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - J Martin Rodriguez
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Angelo Gaffo
- Division of Rheumatology and Clinical Immunology, University of Alabama at Birmingham, Birmingham, AL, United States; Birmingham VA Medical Center, Birmingham, AL, United States
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Weeraddana P, Weerasooriya N, Elkabbani R, Mohamed Jiffry MZ, Nisha N, Sandhu MK. Anaplastic Large-Cell Lymphoma (ALCL) First Manifested as a Rapidly Progressive Acute Respiratory Failure (RF): Lymph Node Biopsy Negative Presentation Posing a Diagnostic Challenge. Cureus 2023; 15:e37619. [PMID: 37197117 PMCID: PMC10184955 DOI: 10.7759/cureus.37619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 05/19/2023] Open
Abstract
Anaplastic large-cell lymphoma (ALCL) is an aggressive subtype of non-Hodgkin lymphoma. There are two forms of ALCL: primary and secondary. Primary can be systemic, affecting multiple organs, or cutaneous, affecting mainly the skin. A secondary form occurs when another lymphoma undergoes an anaplastic transformation. ALCL rarely presents as initial symptoms of respiratory failure. In most of these situations, the trachea or bronchial involved with an obstruction was present. We present an unusual case of ALCL where the patient rapidly progressed to acute hypoxic respiratory failure with a patent bronchus and trachea. Unfortunately, the patient rapidly deteriorated and died before diagnosis. Only upon at autopsy, it was found that his lung parenchyma was diffusely involved with ALCL. The autopsy report showed that the patient had CD-30 anaplastic lymphoma kinase (ALK)-negative ALCL diffusely involving all lung fields.
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Affiliation(s)
| | | | | | | | - Nepal Nisha
- Internal Medicine, Danbury Hospital, Danbury, USA
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8
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Bohm A, Campbell C, Peters C, Datoo N. Timely diagnostics and safe procedures in children with anterior mediastinal masses (AMMs): a qualitative review of the AMM protocol at BC Children's Hospital in Vancouver BC. Pediatr Hematol Oncol 2023; 40:51-64. [PMID: 35920632 DOI: 10.1080/08880018.2022.2072985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The presence of an anterior mediastinal mass should prompt rapid triage, workup and treatment to effectively manage and prevent emergent complications. Implementation of an AMM protocol can ensure the response is standardized and coordinated. Importantly, such a protocol can encourage prompt multi-disciplinary communication to mitigate risks associated with procedures required for timely diagnosis. The aim of this review is to evaluate the BC Children's Hospital's Pediatric New/Suspected Anterior Mediastinal Mass (AMM) Protocol. Retrospective chart review was conducted for 18 patients admitted from February 2016 to May 2020 with AMM for whom the protocol was enacted. Primary parameters assessed presence of high-risk feature at time of presentation, time from admission and/or protocol activation to specific time points, including imaging, first diagnostic procedure, and diagnosis. Data regarding perioperative management, including anesthetic considerations and peri-operative complications, was also collected. Mean time from protocol activation to first diagnostic procedure and diagnosis were 1.88 days (range 0-7) and 2.24 days (range 0-7), respectively. The majority of procedures were conducted under sedation (n = 77, 64%), followed by general anesthetic (GA; n = 34, 28%) and local anesthetic (n = 10, 8%). Despite 15 cases having more than one high risk feature, pre-operative steroids were only administered for four of the total 158 procedures (3%) and extracorporeal life support (ECLS) and otolaryngology (ENT) were only required for immediate availability for seven procedures (4%). Furthermore, only 10 procedures (8%) had associated complications and none of these complications resulted in patient death. Our data demonstrate that implementation of a streamlined multi-disciplinary protocol can expedite time to diagnosis without impacting patient safety.
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Affiliation(s)
- Alexandra Bohm
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Caleigh Campbell
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Cheryl Peters
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Natasha Datoo
- Department of Pediatrics, Division of Pediatric Hematology, Oncology, Blood & Marrow Transplant, University of British Columbia, Vancouver, British Columbia, Canada
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Chung SR, Kim GJ, Choi YJ, Cho KJ, Suh CH, Kim SC, Baek JH, Lee JH, Yang MK, Sa HS. Clinical and Radiological Features of Diffuse Lacrimal Gland Enlargement: Comparisons among Various Etiologies in 91 Biopsy-Confirmed Patients. Korean J Radiol 2022; 23:976-985. [PMID: 36098340 PMCID: PMC9523236 DOI: 10.3348/kjr.2022.0233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 11/15/2022] Open
Abstract
Objective To compare the clinical and radiological features of various etiologies of chronic diffuse lacrimal gland enlargement. Materials and Methods We retrospectively reviewed 91 consecutive patients who underwent surgical biopsy for chronic diffuse lacrimal gland enlargement and were diagnosed with non-specific dacryoadenitis (DA) (n = 42), immunoglobulin G4-related dacryoadenitis (IgG4-RD) (n = 33), and lymphoma (n = 16). Data on patient demographics, clinical presentation, and CT imaging findings (n = 73) and MRI (n = 43) were collected. The following radiologic features of lacrimal gland enlargement were evaluated: size, unilaterality, wedge sign, angle with the orbital wall, heterogeneity, signal intensity, degree of enhancement, patterns of dynamic contrast-enhanced, and apparent diffusion coefficient value. Radiological features outside the lacrimal glands, such as extra-lacrimal orbital involvement and extra-orbital head and neck involvement, were also evaluated. The clinical and radiological findings were compared among the three diseases. Results Compared to the DA and IgG4-RD groups, the lymphoma group was significantly older (mean 59.9 vs. 46.0 and 49.4 years, respectively; p = 0.001) and had a higher frequency of unilateral involvement (62.5% vs. 31.0% and 15.2%, respectively; p = 0.004). Compared to the IgG4-RD and lymphoma groups, the DA group had significantly smaller lacrimal glands (2.3 vs. 2.8 and 3.3 cm, respectively; p < 0.001) and a lower proportion of cases with a wedge sign (54.8% vs. 84.8% and 87.5%, respectively; p = 0.005). The IgG4-RD group showed more frequent involvement of the extra-orbital head and neck structures, including the infraorbital nerve (36.4%), paranasal sinus (72.7%), and salivary gland (58.6%) compared to the DA and lymphoma groups (4.8%–28.6%) (all p < 0.005). Conclusion Patient age, unilaterality, lacrimal gland size, wedge sign, and extra-orbital head and neck involvement differed significantly different between lymphoma, DA, and IgG4-RD. Our results will be useful for the differential diagnosis and proper management of chronic lacrimal gland enlargement.
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Affiliation(s)
- Sae Rom Chung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gye Jung Kim
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Jun Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Kyung-Ja Cho
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo Chin Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hyun Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Kyu Yang
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho-Seok Sa
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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10
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ESTRO ACROP guidelines for external beam radiotherapy of patients with complicated bone metastases. Radiother Oncol 2022; 173:240-253. [DOI: 10.1016/j.radonc.2022.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 12/19/2022]
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11
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Leung KKY, Ku SW, Hon KL, Chigaru L, Chiang AKS, Kan EYL, Oberender F. Recommendations on the Management of Interhospital Transport of Pediatric Patients With Mediastinal Mass. Pediatr Emerg Care 2022; 38:e1104-e1111. [PMID: 34417789 DOI: 10.1097/pec.0000000000002517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Children with mediastinal masses often present with insidious symptoms to nonspecialist centers and require interhospital transport to oncology centers for definitive care. We evaluated clinical characteristics and patient outcomes and proposed a management protocol. MATERIALS AND METHODS This is a retrospective review of all children with mediastinal mass at the pediatric intensive care unit of the Hong Kong Children's Hospital between April 2019 and March 2020. RESULTS Ten children with a median age of 14.5 years (interquartile range, 9.3-17.0 years) were included. Leukemia and lymphoma accounted for the majority of cases (n = 6, 60%). Nearly all patients (n = 9, 90%) required interhospital transport before definitive treatment could be instituted. There were no deaths, but 2 patients were transported with significant respiratory compromise. Among patients requiring more than 1 interhospital transport, there was a higher incidence of shortness of breath (100% vs 40%; odds ratio, 33; P = 0.048) and orthopnea (80% vs 0%; odds ratio, 33; P = 0.048), whereas none had a neck mass (0% vs 80%; odds ratio, 0.03; P = 0.048). CONCLUSIONS Children with mediastinal mass are at risk of life-threatening cardiorespiratory compromise. Pretransport assessment, planning, and stabilization along with clear management plans for deterioration during transport are crucial especially for patients who are symptomatic at time of presentation, to reduce risks associated with delays in arriving at the specialist point of care for definitive treatment.
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Affiliation(s)
- Karen Ka Yan Leung
- From the Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Shu Wing Ku
- From the Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Kam Lun Hon
- From the Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Linda Chigaru
- Children's Acute Transport Service and Paediatric Anaesthesia, Great Ormond Street Hospital, London, United Kingdom
| | | | - Elaine Y L Kan
- Department of Radiology, Hong Kong Children's Hospital, Hong Kong
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children's Hospital Melbourne, Clayton, Australia
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12
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Durrani AF, Jayasundera KT, Conrady CD. Diagnostic Dilemmas With a Great Ocular Masquerader. JAMA Ophthalmol 2022; 140:432-433. [PMID: 35175292 DOI: 10.1001/jamaophthalmol.2021.5241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Asad F Durrani
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - K Thiran Jayasundera
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Christopher D Conrady
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor.,Department of Ophthalmology and Visual Sciences, University of Nebraska Medical Center, Omaha
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13
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Halepota HF, Tan JSK, Reddy SK, Tang PH, Ong LY, Lee YT, Chan MY, Soh SY, Chang KTE, Ng ASB, Loh AHP. Association of anesthetic and surgical risk factors with outcomes of initial diagnostic biopsies in a current cohort of children with anterior mediastinal masses. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000303. [DOI: 10.1136/wjps-2021-000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/06/2021] [Indexed: 11/03/2022] Open
Abstract
BackgroundDiagnostic biopsies of pediatric anterior mediastinal masses (AMMs) are high-risk procedures in which general anesthesia (GA) is traditionally avoided. However, awareness of historically recognized risk factors and corresponding perioperative management have improved over time and may now no longer strictly preclude the use of GA. Therefore, in this study, we examined the association of anesthetic and surgical risk factors and modalities with resulting procedural and survival outcomes in a current patient cohort.MethodsWe retrospectively reviewed charts of 35 children with AMMs who underwent initial diagnostic biopsies between January 2001 and August 2019, and determined tracheal compression and deviation from archival CT scans and procedural and disease outcomes.ResultsTwenty-three (65%) patients underwent GA while 12 (35%) received sedation. Among patients with available CT measurements, 13 of 25 (52%) had >50% anteroposterior tracheal diameter reduction. Patients with >50% anteroposterior tracheal compression received sedation more frequently (p=0.047) and were positioned upright (p=0.015) compared with patients with ≤50% compression, although 4 of 13 and 9 of 12, respectively, still received GA. Intraoperative adverse events (AEs) occurred in four (11.4%) patients: three received GA, and all were positioned supine or lateral. AEs were not associated with radiographic airway risk factors but were significantly associated with morphine and sevoflurane use (p<0.001) and with thoracoscopic biopsies (p=0.035). There were no on-table mortalities, but four delayed deaths occurred (three related to disease and one from late procedural complications).ConclusionsIn a current cohort of pediatric AMM biopsies, patients with >50% anteroposterior tracheal compression were more frequently managed with a conservative perioperative management strategy, though not completely excluding GA. The corresponding reduction in frequency of procedural AEs in this traditionally high-risk group suggests that increased awareness of procedural risk factors and appropriate risk-guided perioperative management choices may obviate the procedural mortality historically associated with pediatric AMM biopsies.
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14
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Fleming JM, Ross S, Hoffman LM, Coughlin R, Crombleholme TM, Mong DA, Hilden J, Maloney K, Tan GM. Pediatric mediastinal mass algorithm: A quality improvement initiative to reduce time from presentation to biopsy. Paediatr Anaesth 2021; 31:885-893. [PMID: 34002917 DOI: 10.1111/pan.14210] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mediastinal masses in children may present with compression of the great vessels and airway. An interdisciplinary plan for rapid diagnosis, acute management, and treatment prevents devastating outcomes and optimizes care. Emergency pretreatment with steroids or radiation is more likely to be administered when care is variable, which may delay and complicate diagnosis and treatment. Strategies to standardize care and expedite diagnosis may improve acute patient safety and long-term outcomes. AIMS The aim of this quality improvement project was to decrease time from presentation to diagnostic biopsy for children with an anterior mediastinal mass by 50% over 3 years within a tertiary healthcare system. METHODS This quality improvement project involved a single center with data collected and analyzed retrospectively and prospectively for 71 patients presenting with anterior mediastinal mass between February 2008 and January 2018. The Model for Improvement was utilized for project design and development of a driver diagram and smart aim. An algorithm was implemented to facilitate communication between teams and standardize initial care of patients with mediastinal masses. The algorithm underwent multiple Plan-Do-Study-Act (PDSA) cycles. Data were collected before and after algorithm implementation and between each PDSA cycle. The primary outcome measure included time from presentation to biopsy, which was monitored with a statistical process control chart. Several process measures were evaluated with Student's t-tests including administration of emergency pretreatment. RESULTS Nineteen patients preintervention and 52 patients postintervention were included in the analysis. Time from presentation to biopsy significantly decreased from 48 h at baseline to 24 h postimplementation. Although not statistically significant, emergency pretreatment decreased from a baseline of 26.3% to 6.7% postimplementation. CONCLUSION Implementation of a diagnostic and management algorithm coordinating care among multidisciplinary teams significantly reduced time to biopsy for children presenting with mediastinal mass and may result in decreased use of emergent pretreatment.
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Affiliation(s)
- Jamie M Fleming
- Anschutz Medical Center, University of Colorado Denver, Aurora, CO, USA
| | - Savannah Ross
- Anschutz Medical Center, University of Colorado Denver, Aurora, CO, USA
| | | | - Rebecca Coughlin
- Anschutz Medical Center, University of Colorado Denver, Aurora, CO, USA
| | | | - David A Mong
- Anschutz Medical Center, University of Colorado Denver, Aurora, CO, USA
| | - Joanne Hilden
- Anschutz Medical Center, University of Colorado Denver, Aurora, CO, USA
| | - Kelly Maloney
- Anschutz Medical Center, University of Colorado Denver, Aurora, CO, USA
| | - Gee Mei Tan
- Anschutz Medical Center, University of Colorado Denver, Aurora, CO, USA
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15
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Leung KKY, Hon KL, Hui WF, Leung AK, Li CK. Therapeutics for paediatric oncological emergencies. Drugs Context 2021; 10:dic-2020-11-5. [PMID: 34234831 PMCID: PMC8232653 DOI: 10.7573/dic.2020-11-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/20/2021] [Indexed: 12/19/2022] Open
Abstract
Background With advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies. Methods An extensive PubMed® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years. Results The general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life. Conclusions Oncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.
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Affiliation(s)
- Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Wun Fung Hui
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Chi Kong Li
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong.,Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
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16
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Keino D, Sudo A, Mizuno M, Sasaki K, Kinoshita A, Mori T. Diffuse Large B-Cell Lymphoma of the Trachea in a Child With Symptoms of Bronchial Asthma. J Pediatr Hematol Oncol 2021; 43:e187-e190. [PMID: 32366783 DOI: 10.1097/mph.0000000000001817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 04/01/2020] [Indexed: 11/26/2022]
Abstract
Tracheal tumors are rare in children and manifest symptoms of airway obstruction. A 14-year-old boy with a 5-month history of dyspnea and wheezing was referred to our hospital. Although he had been initially diagnosed with bronchial asthma, computed tomography revealed tracheal tumors. Histologic examination showed only necrotic tissue. Thereafter, the systemic steroid treatment for bronchial asthma was tapered off. A second computed tomography scan revealed new lesions in the pancreas and lung. Biopsy of the pancreatic lesion revealed a diffuse large B-cell lymphoma. The patient was administered standard chemotherapy, following which he went into complete remission.
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Affiliation(s)
- Dai Keino
- Department of Pediatrics, St. Marianna University School of Medicine
- Division of Hematology/Oncology, Kanagawa Children's Medical Center
| | - Akina Sudo
- Department of Pediatrics, St. Marianna University School of Medicine
| | - Masanori Mizuno
- Department of Pediatrics, St. Marianna University School of Medicine
| | - Keigo Sasaki
- Department of Pediatrics, Yokohama Rosai Hospital, Kanagawa, Japan
| | | | - Tetsuya Mori
- Department of Pediatrics, St. Marianna University School of Medicine
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17
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Blood JD, Khan A, Kamdar K, Foradori DM. Fever, Headache, and Sore Throat in a 7-year-old Girl. Pediatr Rev 2021; 42:S89-S92. [PMID: 33386372 DOI: 10.1542/pir.2019-0200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Julia D Blood
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Adrita Khan
- Department of Pediatrics, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Kala Kamdar
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Dana M Foradori
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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18
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Nachtsheim L, Wittersheim M, Kreissl S, Klussmann JP, Grosheva M. Facial nerve paralysis caused by a T-cell lymphoma. Clin Case Rep 2020; 8:2965-2968. [PMID: 33363860 PMCID: PMC7752436 DOI: 10.1002/ccr3.3285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/22/2020] [Accepted: 08/01/2020] [Indexed: 12/01/2022] Open
Abstract
Facial nerve paralysis due to the infiltration by a lymphoma is rare and the prognosis remains poor. If perineural spread and meningeosis are suspected, quick interdisciplinary diagnostic work-up is recommended. It should include magnetic resonance imaging, biopsy of the lesion, bone marrow biopsy, and lumbar puncture. Therapy should be initiated immediately.
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Affiliation(s)
- Lisa Nachtsheim
- Department of Otorhinolaryngology, Head and Neck SurgeryMedical FacultyUniversity of CologneCologneGermany
| | - Maike Wittersheim
- Department of PathologyMedical FacultyUniversity of CologneCologneGermany
| | - Stefanie Kreissl
- Department I of Internal Medicine and Center of Integrated OncologyMedical FacultyUniversity of CologneCologneGermany
| | - Jens Peter Klussmann
- Department of Otorhinolaryngology, Head and Neck SurgeryMedical FacultyUniversity of CologneCologneGermany
| | - Maria Grosheva
- Department of Otorhinolaryngology, Head and Neck SurgeryMedical FacultyUniversity of CologneCologneGermany
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19
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To What Extent Can Orbital Cellulitis Emergency Aspect Influence the Diagnosis of Maxillary Sinus Lymphoma? Case Rep Ophthalmol Med 2020; 2020:2304861. [PMID: 32328330 PMCID: PMC7168696 DOI: 10.1155/2020/2304861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/25/2020] [Indexed: 11/17/2022] Open
Abstract
We present a case of a 46-year-old woman admitted to the emergency department for acute swelling and erythema of the right eyelid for 3 days. Ophthalmological examination was notable for 10/10, P2 best visual acuity, and inflammatory periorbital edema, without exophthalmia nor extraocular motility disturbance. Intraocular pressure was 14 mmHg and fundoscopic examination was not notable for any abnormality. Preseptal cellulitis diagnosis was made, and oral antibiotherapy was immediately started; after 72 hours, the patient did not improve and started complaining of pain on ocular movements. Brain and orbit MRI scan revealed right retroseptal cellulitis associated with homolateral pansinusitis. Intravenous antibiotherapy with oral corticosteroid was started simultaneously leading to full remission but with steroid dependency; 5 days after finishing prednisone, orbital cellulitis symptoms reappeared. The same treatment protocol was given but with corticosteroid tapering over weeks. Nevertheless, steroid dependency persisted. Except for the inflammatory syndrome, complete biological examinations did not disclose any abnormalities. The patient underwent maxillary sinus and fat orbital biopsy; however, histopathological examination was not contributory. Persistence of steroid dependency, chronic atypical rhinosinusitis, normal paraclinical investigations, and age of patient let us suspect lymphoma origin hidden by chronic corticosteroid. We carried out for the second time a maxillary sinus biopsy after stopping steroids, which disclosed primitive non-Hodgkin lymphoma of the maxillary sinus. The aim of this observation is firstly to evoke though it is exceptional the diagnosis of maxillary lymphoma in case of atypical orbital cellulitis and secondly to incite clinicians to be more vigilant in prescribing corticosteroid even if there is an emergency character of orbital cellulitis.
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20
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Ketterl TG, Latham GJ. Perioperative Cardiothoracic and Vascular Risk in Childhood Cancer and its Survivors. J Cardiothorac Vasc Anesth 2020; 35:162-175. [PMID: 32360009 DOI: 10.1053/j.jvca.2020.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/11/2020] [Accepted: 02/28/2020] [Indexed: 11/11/2022]
Abstract
CHILDREN with cancer and survivors of childhood cancer have an increased risk of cardiovascular disease, and this risk in the perioperative period must be understood. During diagnosis and treatment of pediatric cancer, multiple acute cardiovascular morbidities are possible, including anterior mediastinal mass, tamponade, hypertension, cardiomyopathy,and heart failure. Childhood cancer survivors reaching late childhood and adulthood experience substantially increased rates of cardiomyopathy, heart failure, valvular disease, pericardiac disease, ischemia, and arrhythmias. Despite considerable advances in the understanding and therapeutic options of pediatric malignancies, cardiac disease remains the most common treatment-related, noncancer cause of death in childhood cancer survivors. Increasingly, molecularly targeted agents, including small molecule inhibitors, are being incorporated into pediatric oncology. The acute and chronic risks associated with these newer therapeutic options in children are not yet well-described, which poses challenges for clinicians caring for these patients. In the present review, the unique risks factors, prevention strategies, and treatment of cardiovascular toxicities of the child with cancer and the childhood cancer survivor are examined, with an emphasis on the perioperative period.
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Affiliation(s)
- Tyler G Ketterl
- Department of Pediatric Hematology and Oncology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
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21
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Reddy CSK, Phang DLK, Ng ASB, Tan AM. A simplified approach for anaesthetic management of diagnostic procedures in children with anterior mediastinal mass. Singapore Med J 2019; 61:308-311. [PMID: 31680177 DOI: 10.11622/smedj.2019139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Children with an anterior mediastinal mass (AMM) need general anaesthesia (GA) or deep sedation for diagnostic procedures more often than adult patients. Anaesthetic management to prevent such complications includes maintenance of spontaneous ventilation (SV) and prebiopsy corticosteroids/radiotherapy. METHODS We reviewed the medical records of children with AMM who were brought to the operating theatre for diagnostic procedures (prior to chemotherapy) between 2001 and 2013. Our aim was to describe the clinical features, radiological findings and anaesthetic management, as well as determine any association with complications. RESULTS 25 patients (age range 10 months-14 years) were identified during the study period. Corticosteroid therapy was started before the biopsy for one patient. All 25 patients had GA/sedation. A senior paediatric anaesthesiologist was involved in all procedures. Among 13 high-risk patients, SV was maintained in 11 (84.6%) patients, ketamine was used as the main anaesthetic in 8 (61.5%) patients, 6 (46.2%) patients were in a sitting position and no airway adjunct was used for 7 (53.8%) patients. There were 3 (12.0%) minor complications. CONCLUSION Based on our results, we propose a simplified workflow, wherein airway compression of any degree is considered high risk. For patients with high-risk features, multidisciplinary input should be sought to decide whether the child would be fit for a procedure under GA/sedation or considered unfit for any procedure. Recommendations include the use of less invasive methods, involving experienced anaesthesiologists to plan the anaesthetic technique and maintaining SV.
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Affiliation(s)
| | | | - Agnes Suah Bwee Ng
- Department of Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Ah Moy Tan
- Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
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22
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Kitahara T, Imamura S, Ohta M, Okoshi T, Kobori A, Miyakoshi A, Oichi Y, Toda H. Two cases of primary ocular adnexal lymphomas diagnosed after pre-biopsy corticosteroid treatment using polymerase chain reaction-based gene rearrangement analysis. Am J Ophthalmol Case Rep 2019; 15:100520. [PMID: 31372582 PMCID: PMC6658928 DOI: 10.1016/j.ajoc.2019.100520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 06/14/2019] [Accepted: 07/15/2019] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To report the limited usefulness of polymerase chain reaction (PCR)-based immunoglobulin (Ig) and T-cell receptor (TCR) gene rearrangement analysis in diagnosing primary ocular adnexal lymphomas (OAL) treated with corticosteroids before biopsy. OBSERVATIONS This was a case series of two patients: a 47-year-old woman and a 43-year-old man, who both presented with impaired visual acuity and ophthalmoplegia of the involved eyes. Both patients had previously received non-diagnostic biopsy and had been subsequently treated with corticosteroids. The visual acuity and ophthalmoplegia progressively worsened after a variable duration of remission. Ocular magnetic resonance imaging revealed gadolinium-enhancing intra- and extraconal lesions. Systemic evaluations did not reveal any other lesions outside of the orbit. Differential diagnoses were lymphoproliferative disorders, including undiagnosed primary OALs, and idiopathic ocular inflammation. Both patients were exposed to repeated biopsies. The biopsied tissue demonstrated marked lymphocytolysis due to corticosteroid usage; therefore, histology and immunophenotype were non-diagnostic. EuroClonality/BIOMED-2 PCR-based gene rearrangement analyses detected genetic clonalities of Ig and TCR and suggested diagnoses of primary OALs of B-cell and T-cell origins, respectively. An OAL of B-cell origin was treated with radiotherapy; an OAL of a rare T-cell origin was treated with high-dose methotrexate-based chemotherapy and adjuvant radiotherapy. Both patients remained progression free for more than 36 months. CONCLUSIONS AND IMPORTANCE PCR-based gene rearrangement analysis can be of limited usefulness in suggesting a diagnosis of primary OAL in patients receiving pre-biopsy corticosteroid treatment. Identification of genetic clonality is of clinical importance to provide treatment options for undiagnosed OALs.
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Affiliation(s)
| | - Shin Imamura
- Department of Hematology, Fukui Red Cross Hospital, Fukui, Japan
| | - Makoto Ohta
- Department of Pathology, Fukui Red Cross Hospital, Fukui, Japan
| | - Tadakazu Okoshi
- Department of Pathology, Fukui Red Cross Hospital, Fukui, Japan
| | - Akira Kobori
- Department of Ophthalmology, Fukui Red Cross Hospital, Fukui, Japan
| | | | - Yuki Oichi
- Department of Neurosurgery, Fukui Red Cross Hospital, Fukui, Japan
| | - Hiroki Toda
- Department of Neurosurgery, Fukui Red Cross Hospital, Fukui, Japan
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23
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Mombaerts I, Ramberg I, Coupland SE, Heegaard S. Diagnosis of orbital mass lesions: clinical, radiological, and pathological recommendations. Surv Ophthalmol 2019; 64:741-756. [PMID: 31276737 DOI: 10.1016/j.survophthal.2019.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 02/07/2023]
Abstract
The orbit can harbor mass lesions of various cellular origins. The symptoms vary considerably according to the nature, location, and extent of the disease and include common signs of proptosis, globe displacement, eyelid swelling, and restricted eye motility. Although radiological imaging tools are improving, with each imaging pattern having its own differential diagnosis, orbital mass lesions often pose a diagnostic challenge. To provide an accurate, specific, and sufficiently comprehensive diagnosis, to optimize clinical management and estimate prognosis, pathological examination of a tissue biopsy is essential. Diagnostic orbital tissue biopsy is obtained through a minimally invasive orbitotomy procedure or, in selected cases, fine needle aspiration. The outcome of successful biopsy, however, is centered on its representativeness, processing, and interpretation. Owing to the often small volume of the orbital biopsies, artifacts in the specimens should be limited by careful peroperative tissue handling, fixation, processing, and storage. Some orbital lesions can be characterized on the basis of cytomorphology alone, whereas others need ancillary molecular testing to render the most reliable diagnosis of therapeutic, prognostic, and predictive value. Herein, we review the diagnostic algorithm for orbital mass lesions, using clinical, radiological, and pathological recommendations, and discuss the methods and potential pitfalls in orbital tissue biopsy acquisition and analysis.
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Affiliation(s)
- Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium.
| | - Ingvild Ramberg
- Department of Ophthalmology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Section of Eye Pathology, Department of Pathology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah E Coupland
- Department of Cellular and Molecular Pathology, University of Liverpool, Liverpool, UK; Liverpool Clinical Laboratories, Royal Liverpool University Hospital, Liverpool, UK
| | - Steffen Heegaard
- Department of Ophthalmology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Section of Eye Pathology, Department of Pathology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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24
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Clinicopathologic features of biopsied lacrimal gland masses in 95 Korean patients. Graefes Arch Clin Exp Ophthalmol 2019; 257:1527-1533. [PMID: 31025214 DOI: 10.1007/s00417-019-04327-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 04/10/2019] [Accepted: 04/15/2019] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To investigate the clinicopathologic features of lacrimal gland masses biopsied in a tertiary referral hospital in Korea. METHODS Records from 95 Korean patients who underwent lacrimal gland mass biopsy were retrospectively reviewed. Data included demographics, clinical presentation, imaging findings, histopathologic diagnosis, and associated systemic disease. RESULTS The median age was 52.0 years (range, 16-76 years), and 51 patients (53.7%) were female. Thirty-three patients (34.7%) had bilateral disease. The histopathologic diagnoses were as follows: chronic dacryoadenitis (52.6%, n = 50;29 non-specific and 21 immunoglobulin G4-related disease (IgG4-RD)), lymphoproliferative disease (25.5%, n = 24; 18 lymphoma and six lymphoid hyperplasia), benign epithelial tumour (13.7%, 13 pleomorphic adenoma), malignant epithelial tumour (3.2%, three adenoid cystic carcinoma), dacryops (3.2%, n = 3), solitary fibrous tumour (1.1%, n = 1), and xanthogranulomatous inflammation (1.1%, n = 1). Patients with chronic dacryoadenitis were significantly more likely to be younger (mean 47.5 years), have bilateral involvement (52.0%), and have a longer symptom period (mean 15.6 months) than those with lymphoproliferative disease (60.0 years, 25.0%, and 6.7 months, respectively; p < 0.05, each comparison). Patients with IgG4-related dacryoadenitis were significantly more likely to have bilateral involvement (85.7%) and have associated systemic involvement (52.4%) than those with non-specific dacryoadenitis (37.9 and 0%, respectively; p < 0.05, each comparison). Sixteen patients (16.8%) had associated systemic involvement: 11 with IgG4-RD and 5 with lymphoma. CONCLUSIONS Chronic dacryoadenitis and lymphoproliferative disease were the most common causes of lacrimal gland masses in our cohort. Younger patients with bilateral involvement and a longer symptom period were more likely to have chronic dacryoadenitis than lymphoproliferative disease. Associated systemic involvement was not rare in patients with IgG4-RD or lymphoma. Our results suggest that biopsy of chronic lacrimal gland masses should be performed for proper evaluation and management.
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Malik R, Mullassery D, Kleine-Brueggeney M, Atra A, Gour A, Sunderland R, Okoye B. Anterior mediastinal masses - A multidisciplinary pathway for safe diagnostic procedures. J Pediatr Surg 2019; 54:251-254. [PMID: 30503023 DOI: 10.1016/j.jpedsurg.2018.10.080] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective of this study was to report our multidisciplinary diagnostic approach for patients with anterior mediastinal masses (AMM). METHODS A retrospective review of patients with AMM at a tertiary pediatric surgical oncology centre (January 2011-December 2016) was performed. We analyzed data on clinical presentation, mode of tissue diagnosis, anesthetic techniques, and complications. RESULTS Of the 44 patients admitted with AMM (median age 11 years, 27 males and 17 females), 22 had respiratory symptoms. Imaging revealed tracheobronchial compression in 26 children. Twenty patients had a lymph node biopsy. Ten patients had image-guided core biopsy of the mediastinal mass, and 2 had mediastinoscopic biopsy of a paratracheal lymph node. One patient with likely recurrence of a relapsed metastatic ethmoid carcinoma did not have a biopsy. The diagnosis was made from alternative tissues, such as pleural fluid in 4 and peripheral blood in 7 patients. Twenty-five anesthetics were assessed, as 14 patients required no or only local anesthesia, and 5 had unavailable anesthetic notes. Eighteen of 25 patients were anesthetized maintaining spontaneous breathing, mostly by means of ketamine sedation. There were no major anesthetic complications. CONCLUSION Safe tissue diagnosis of anterior mediastinal masses can be obtained by a personalized multidisciplinary approach. Use of alternative tissues, local anesthesia, and ketamine sedation help minimize the need for general anesthesia, muscle paralysis, and controlled ventilation. LEVEL OF EVIDENCE IV (Case Series with no Comparison Group).
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Affiliation(s)
- Rubina Malik
- Department of Paediatric Oncology, St George's Hospital NHS Trust, London, UK
| | - Dhanya Mullassery
- Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - Maren Kleine-Brueggeney
- Department of Anaesthesia, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Ayad Atra
- Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - Anami Gour
- Department of Paediatric Intensive Care Medicine, St Georges Hospital NHS Trust
| | - Robin Sunderland
- Department of Paediatric Anaesthesia, St Georges Hospital NHS Trust, London, UK
| | - Bruce Okoye
- Department of Paediatric Surgery, St Georges Hospital NHS Trust, London, UK.
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Kawaguchi Y, Saito T, Mitsunaga T, Terui K, Nakata M, Matsuura G, Kouchi K, Yoshida H. Prediction of respiratory collapse among pediatric patients with mediastinal tumors during induction of general anesthesia. J Pediatr Surg 2018; 53:1365-1368. [PMID: 29037532 DOI: 10.1016/j.jpedsurg.2017.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/26/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Fatality resulting from respiratory collapse (RC) during general anesthesia (GA) induction in children with mediastinal tumors has been reported. We explored potentially useful parameters for predicting the risk of RC based on objective imaging results. METHODS We retrospectively reviewed the records of 31 patients (median age: 4years; range: 4months-15years) with mediastinal tumors treated between 2000 and 2015. Comparing those with RC under GA induction to those without (RC group vs. non-RC group), we analyzed a variety of factors that might predict respiratory obstruction during GA induction, including our new parameter, the standardized tumor volume (STV), which is adapted from the formula for the volume of an ellipsoid. RESULTS All eight patients in the RC group had large tumors in the anterior mediastinum, including lymphoma, teratoma, and germ cell tumor. The mean STV value of the RC group was significantly larger than that of the non-RC group (3.6±1.4 vs. 1.4±1.0, p=0.006). Using an STV cut-off value of 2.5, the sensitivity and specificity for predicting RC under GA induction were both 0.86, making STV more useful than previously reported risk factors. CONCLUSION Anterior mediastinal tumors in children can often cause airway obstruction under GA induction. Measuring STV can help predict the respiratory risk during GA among pediatric patients with anterior mediastinal tumors. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yunosuke Kawaguchi
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8677, Japan
| | - Takeshi Saito
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8677, Japan.
| | - Tetsuya Mitsunaga
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8677, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8677, Japan
| | - Mitsuyuki Nakata
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8677, Japan
| | - Gen Matsuura
- Department of Pediatric Surgery, Matsudo City Hospital Children's Medical Centre, 4005 Kamihongo, Matsudo City, Chiba 271-8511, Japan
| | - Katsunori Kouchi
- Department of Pediatric Surgery, Tokyo Women's Medical University Yachiyo Medical Center, 477-96 Owadashinden, Yachiyo City, Chiba 276-8524, Japan
| | - Hideo Yoshida
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8677, Japan
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Sodji Q, Kaminski J, Willey C, Kim N, Mourad W, Vender J, Dasher B. Management of Metastatic Spinal Cord Compression. South Med J 2017; 110:586-593. [DOI: 10.14423/smj.0000000000000700] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Takeshige T, Harada N, Sekimoto Y, Kanemaru R, Tsutsumi T, Matsuno K, Shiota S, Masuda A, Gotoh A, Asahina M, Uekusa T, Takahashi K. Pulmonary Intravascular Large B-cell Lymphoma (IVLBCL) Disguised as an Asthma Exacerbation in a Patient with Asthma. Intern Med 2017; 56:1885-1891. [PMID: 28717087 PMCID: PMC5548684 DOI: 10.2169/internalmedicine.56.7613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
A 62-year-old man with asthma presented with a 1-month history of wheezing and exertional dyspnea. Although the wheezing symptoms disappeared after systemic corticosteroid therapy, the exertional dyspnea and hypoxemia did not improve. A diagnosis of intravascular large B-cell lymphoma (IVLBCL) with pulmonary involvement was suspected because of the increased serum lactic dehydrogenase (LDH) and soluble interleukin-2 receptor (sIL-2R) level, increased alveolar-arterial oxygen difference (AaDO2), decreased pulmonary diffusing capacity for carbon monoxide (DLCO) and scintigraphic, computed tomography (CT) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT findings. The patient was diagnosed as having IVLBCL with pulmonary involvement based on a pathological analysis of a random skin biopsy and a transbronchial lung biopsy. IVLBCL should be considered in patients with symptoms of asthma that are refractory to corticosteroid treatment.
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Affiliation(s)
- Tomohito Takeshige
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Norihiro Harada
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Yasuhito Sekimoto
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Ryota Kanemaru
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Takeo Tsutsumi
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Kei Matsuno
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Satomi Shiota
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Azuchi Masuda
- Department of Hematology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Akihiko Gotoh
- Department of Hematology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Miki Asahina
- Department of Human Pathology, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
| | - Toshimasa Uekusa
- Department of Pathology, Labour Health and Welfare Organization Kanto Rosai Hospital, Japan
| | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Japan
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Myers KA, Nikolic A, Romanchuk K, Weis E, Brundler MA, Lafay-Cousin L, Costello F. Optic neuropathy in the context of leukemia or lymphoma: diagnostic approach to a neuro-oncologic emergency. Neurooncol Pract 2016; 4:60-66. [PMID: 31386008 DOI: 10.1093/nop/npw006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Indexed: 11/12/2022] Open
Abstract
Background Optic neuropathy in the context of leukemia or lymphoma has a broad differential diagnosis, including infiltration, infection, inflammation, compression, and medication effects. Confirming the underlying etiology in a timely manner is crucial as, while infiltration carries a poor prognosis, treatment modalities can have serious consequences themselves. Methods A review of the literature was conducted for cases of isolated optic neuropathy in the context of leukemia or lymphoma, in which the underlying etiology remained unclear following initial clinical examination and neuroimaging. Clinical, radiological, and pathological characteristics of the cases are summarized. Results Ninety-two cases meeting inclusion criteria were identified. Leukemic or lymphomatous infiltration was the presumed diagnosis in 72% of the reports, indicating this is the most likely etiology in such cases. The remaining reports were attributed to inflammation, infection, or drug toxicity. For illustrative purposes, the previously unpublished case of an 11-year-old girl with remitted T lymphoblastic lymphoma is presented. She suffered recurrence in the form of isolated left optic nerve infiltration that required transconjunctival biopsy to confirm diagnosis. Conclusions Optic nerve infiltration by leukemia or lymphoma requires both diagnostic certainty and urgent management. Recommendations are made for a step-wise, yet rapid investigative approach that may ultimately require biopsy of the optic nerve.
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Affiliation(s)
- Kenneth A Myers
- Department of Pediatrics, Section of Neurology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.A.M.); Department of Pathology & Laboratory Medicine; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (A.N.); Department of Ophthalmology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.R); Department of Ophthalmology and Visual Sciences, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada (E.W.); Departments of Pathology & Laboratory Medicine and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (M.-A.B.); Departments of Oncology and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (L.L.-C.); Department of Clinical Neurosciences; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (F.C.)
| | - Ana Nikolic
- Department of Pediatrics, Section of Neurology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.A.M.); Department of Pathology & Laboratory Medicine; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (A.N.); Department of Ophthalmology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.R); Department of Ophthalmology and Visual Sciences, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada (E.W.); Departments of Pathology & Laboratory Medicine and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (M.-A.B.); Departments of Oncology and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (L.L.-C.); Department of Clinical Neurosciences; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (F.C.)
| | - Kenneth Romanchuk
- Department of Pediatrics, Section of Neurology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.A.M.); Department of Pathology & Laboratory Medicine; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (A.N.); Department of Ophthalmology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.R); Department of Ophthalmology and Visual Sciences, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada (E.W.); Departments of Pathology & Laboratory Medicine and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (M.-A.B.); Departments of Oncology and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (L.L.-C.); Department of Clinical Neurosciences; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (F.C.)
| | - Ezekiel Weis
- Department of Pediatrics, Section of Neurology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.A.M.); Department of Pathology & Laboratory Medicine; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (A.N.); Department of Ophthalmology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.R); Department of Ophthalmology and Visual Sciences, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada (E.W.); Departments of Pathology & Laboratory Medicine and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (M.-A.B.); Departments of Oncology and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (L.L.-C.); Department of Clinical Neurosciences; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (F.C.)
| | - Marie-Anne Brundler
- Department of Pediatrics, Section of Neurology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.A.M.); Department of Pathology & Laboratory Medicine; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (A.N.); Department of Ophthalmology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.R); Department of Ophthalmology and Visual Sciences, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada (E.W.); Departments of Pathology & Laboratory Medicine and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (M.-A.B.); Departments of Oncology and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (L.L.-C.); Department of Clinical Neurosciences; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (F.C.)
| | - Lucie Lafay-Cousin
- Department of Pediatrics, Section of Neurology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.A.M.); Department of Pathology & Laboratory Medicine; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (A.N.); Department of Ophthalmology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.R); Department of Ophthalmology and Visual Sciences, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada (E.W.); Departments of Pathology & Laboratory Medicine and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (M.-A.B.); Departments of Oncology and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (L.L.-C.); Department of Clinical Neurosciences; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (F.C.)
| | - Fiona Costello
- Department of Pediatrics, Section of Neurology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.A.M.); Department of Pathology & Laboratory Medicine; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (A.N.); Department of Ophthalmology; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (K.R); Department of Ophthalmology and Visual Sciences, University of Alberta, Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada (E.W.); Departments of Pathology & Laboratory Medicine and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (M.-A.B.); Departments of Oncology and Pediatrics; Alberta Children's Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (L.L.-C.); Department of Clinical Neurosciences; Foothills Hospital, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada (F.C.)
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Band ME, Sheldon C, Brancato J, Parikh NS, D'Alessandri-Silva C. A 17-Year-Old With Steroid-Resistant Nephrotic Syndrome. Pediatrics 2016; 137:peds.2015-3205. [PMID: 27244796 DOI: 10.1542/peds.2015-3205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2015] [Indexed: 11/24/2022] Open
Abstract
A 17-year-old girl presented with facial swelling and shortness of breath to an outside emergency department. She was treated for an allergic reaction with steroids and antihistamines, and discharged from the hospital. Subsequently, she was referred as an outpatient to pediatric nephrology for recurrent edema and proteinuria. Initial laboratory workup by nephrology was significant for a normal complete blood count and reassuring electrolyte panel. Pertinent laboratories were a creatinine of 0.5 mg/dL (0.4-1.1 mg/dL) and an albumin 2.3 g/dL (3.5-5.0 g/dL). The urine protein-to-creatinine ratio was >7 (<0.2). A renal ultrasound showed symmetrically sized kidneys with normal echotexture. The patient's renal biopsy results were consistent with minimal change disease. Based on the biopsy results, prednisone was started. Due to a poor response to prednisone, an alternate immunomodulator therapy was selected. Her subsequent complete blood counts showed a downward trend of all cell lines and an elevated serum uric acid. Concurrently, she reported worsening fatigue, low back pain, nausea, vomiting, night sweats, and pruritus. More details of her case and the outcome are presented.
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Affiliation(s)
- Molly E Band
- Connecticut Children's Medical Center, Hartford, Connecticut; and
| | - Candice Sheldon
- Division of Nephrology, Department of Pediatrics, Stanford School of Medicine, Stanford University, Palo Alto, CA
| | - John Brancato
- Connecticut Children's Medical Center, Hartford, Connecticut; and
| | - Nehal S Parikh
- Connecticut Children's Medical Center, Hartford, Connecticut; and
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Ting DSJ, Perez-Lopez M, Chew NJ, Clarke L. Radiologic-pathologic correlation of orbital diseases. Orbit 2016; 35:159-60. [PMID: 27029808 DOI: 10.3109/01676830.2016.1139599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Ne Jia Chew
- a Newcastle Eye Centre , Newcastle upon Tyne , United Kingdom
| | - Lucy Clarke
- a Newcastle Eye Centre , Newcastle upon Tyne , United Kingdom
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Acker SN, Linton J, Tan GM, Garrington TP, Bruny J, Hilden JM, Hoffman LM, Partrick DA. A multidisciplinary approach to the management of anterior mediastinal masses in children. J Pediatr Surg 2015; 50:875-8. [PMID: 25783332 DOI: 10.1016/j.jpedsurg.2014.09.054] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 09/07/2014] [Accepted: 09/08/2014] [Indexed: 12/17/2022]
Abstract
PURPOSE Anterior mediastinal masses (AMM) pose a diagnostic challenge to surgeons, oncologists, anesthesiologists, intensivists, and interventional radiologists as induction of general anesthesia can cause airway obstruction and cardiovascular collapse. We hypothesized that in the majority of patients, diagnosis can be obtained through biopsy of extrathoracic tissue. METHODS We performed a retrospective review of all patients in the solid tumor oncology clinic with a diagnosis of AMM between 2002 and 2012 including preoperative evaluation and management prior to obtaining a tissue diagnosis, clinical course and complications. RESULTS We identified 69 patients with AMM (mean age 12.2±4.4years, 64% male) secondary to Hodgkin lymphoma (34), Non-Hodgkin lymphoma (26), and other diagnoses (9). The majority of patients (56, 81.2%) underwent biopsy of tissue outside of the mediastinal mass. Local anesthesia with sedation was used for successful biopsy in 21 (30%) patients. Four (5.8%) required repeat biopsy due to inadequate sample obtained at initial procedure. Three (4.4%) suffered respiratory complications with no fatalities or severe complications. CONCLUSIONS Our data demonstrate that in the majority of children with AMM, tissue biopsy can be successfully obtained from tissue outside of the mass itself with minimal complications and highlight the importance of multidisciplinary preoperative planning to minimize anesthetic risks.
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Affiliation(s)
- Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Jacqueline Linton
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Gee Mei Tan
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Timothy P Garrington
- Department of Pediatrics, Section of Pediatric Hematology and Oncology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Jennifer Bruny
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Joanne M Hilden
- Department of Pediatrics, Section of Pediatric Hematology and Oncology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Lindsey M Hoffman
- Department of Pediatrics, Section of Pediatric Hematology and Oncology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
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Henry M, Sung L. Supportive care in pediatric oncology: oncologic emergencies and management of fever and neutropenia. Pediatr Clin North Am 2015; 62:27-46. [PMID: 25435110 DOI: 10.1016/j.pcl.2014.09.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Advancements in the care of children with cancer have, in part, been achieved through improvements in supportive care. Situations that require prompt care can occur at the time of presentation as well as during treatment. This article discusses the approach to children with fever and neutropenia, a complication encountered daily by care providers, as well as oncologic emergencies that can be seen at the time of a child's initial diagnosis: hyperleukocytosis, tumor lysis syndrome, superior vena cava syndrome, and spinal cord compression.
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Affiliation(s)
- Meret Henry
- Division of Hematology/Oncology, Children's Hospital of Michigan/Wayne State University, 3901 Beaubien, Detroit, MI 48201, USA.
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G1X8, Canada
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Linn-Pearl RN, Powell RM, Newman HA, Gould DJ. Validity of aqueocentesis as a component of anterior uveitis investigation in dogs and cats. Vet Ophthalmol 2014; 18:326-34. [PMID: 25557502 PMCID: PMC7169297 DOI: 10.1111/vop.12245] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective To describe aqueocentesis cytopathology results from dogs and cats presenting for uveitis investigation and to determine whether this is a useful and safe procedure. Animal Studied Dogs and cats presenting for investigation of anterior uveitis (April 2008–December 2013). Procedures Aqueous was collected via limbal entry under sedation/general anesthesia, for cytopathology and occasionally bacterial culture or polymerase chain reaction (PCR) testing. Further workup included blood testing (hematology, biochemistry, and serology), diagnostic imaging, nonocular cytopathology, and available histopathology. Results Fifty‐six dogs and 39 cats were included in the study. An aqueous cytopathologic diagnosis of lymphoma (or discrete cell neoplasia) was made in six dogs and seven cats, and a diagnosis of large cell carcinoma made in one dog. This diagnosis of lymphoma was confirmed by ocular histopathology in two dogs and one cat; nonocular cytopathology corroborated lymphoma in another three dogs and five cats. Lymphoma was not evident on aqueous cytopathology but confirmed on nonocular histopathology in two dogs and by cytopathology in one cat. Additionally, aqueous cytopathology in three cats suggested, but was not considered diagnostic of, lymphoma; one of these cats had a confirmatory diagnosis of lymphoma on subsequent clinical investigation. Aqueous humor cytopathology alone was not diagnostic in non‐neoplastic anterior uveitis cases, but supplemented the clinical picture with other systemic diagnostic tests. No clinically important complications were reported in association with aqueocentesis. Conclusions Aqueocentesis is performed readily with minimal risk. The results were primarily useful in aiding a diagnosis of lymphoma in both dogs and cats.
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Affiliation(s)
- Rose N Linn-Pearl
- Davies Veterinary Specialists, Manor Farm Business Park, Hertfordshire, UK
| | - Roger M Powell
- Powell Torrance Diagnostic Services, Manor Farm Business Park, Hertfordshire, UK
| | - Hayley A Newman
- Davies Veterinary Specialists, Manor Farm Business Park, Hertfordshire, UK
| | - David J Gould
- Davies Veterinary Specialists, Manor Farm Business Park, Hertfordshire, UK
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Mombaerts I, Cameron JD, Chanlalit W, Garrity JA. Surgical Debulking for Idiopathic Dacryoadenitis. Ophthalmology 2014; 121:603-9. [DOI: 10.1016/j.ophtha.2013.09.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/22/2013] [Accepted: 09/08/2013] [Indexed: 12/24/2022] Open
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Jain R, Bansal D, Marwaha RK, Singhi S. Superior mediastinal syndrome: emergency management. Indian J Pediatr 2013; 80:55-9. [PMID: 23054856 DOI: 10.1007/s12098-012-0884-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Accepted: 08/23/2012] [Indexed: 11/26/2022]
Abstract
Superior Vena Cava Syndrome (SVCS) refers to signs and symptoms caused by obstruction of the superior vena cava. Superior mediastinal syndrome (SMS) is the term used when SVCS coexists with obstruction of trachea. In children, a mediastinal pathology causing SVCS generally results in SMS as well, due to the limited chest volume. Hence, the two terms are often used interchangeably in children. SMS is a medical emergency that can be challenging, albeit often rewarding to manage. The common causes in a patient presenting to pediatric emergency room include non-Hodgkin lymphoma and acute lymphoblastic leukemia. Patients with SMS are at a very high risk for adverse cardio-respiratory events in case they are administered any kind of anesthetic agents, anxiolytics or sedatives. Investigations, including tissue diagnosis are desirable, though not mandatory, before initiating emergency management. The patient's clinical condition should dictate the speed, requirement and sequence of investigations and the specific treatment. The least invasive procedure should be performed to confirm the diagnosis. As the most common cause of SMS in children is lymphoma/leukemia, the administration of systemic steroids is often the front line therapy. Diagnosis, monitoring and management of SMS in relevance to the pediatric emergency room are outlined.
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Affiliation(s)
- Richa Jain
- Department of Pediatrics, Pediatric Hematology Oncology Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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US-guided percutaneous needle biopsy of anterior mediastinal masses in children. Pediatr Radiol 2012; 42:40-9. [PMID: 21863292 DOI: 10.1007/s00247-011-2204-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 06/16/2011] [Accepted: 06/21/2011] [Indexed: 01/08/2023]
Abstract
BACKGROUND Anterior mediastinal masses in children are clinically challenging, requiring prompt histological diagnosis. OBJECTIVE The purpose of this study was to review the experience with US-guided percutaneous core needle biopsy (PCNB) of anterior mediastinal masses in children, particularly with respect to safety and diagnostic accuracy. MATERIALS AND METHODS We retrospectively reviewed the clinical presentation, imaging, sedation approach, procedural details and pathology results of US-guided PCNB of mediastinal masses that occurred during an 8-year period (2001-2008). Complications were graded and pathology was categorized into four groups based on adequacy and diagnostic yield. RESULTS 32 US-guided PCNBs were performed on 32 children, mean age 12 years (range 18 months to 17 years), mean weight 48 kg (range 11.5 to 109 kg, median 49 kg). A coaxial US-guided technique was used, with a mean of 8.2 passes and a mean 7.6 cores obtained (range 2-15). There were no major complications. The biopsies were adequate in volume and quality of specimens in 29/32, and 25/32 were diagnostic. PCNB was diagnostic in all cases of non-Hodgkin disease. CONCLUSIONS Experience with anterior mediastinal masses suggests that US-guided PCNB can be considered a viable, safe and accurate method of reaching a diagnosis in the pediatric population.
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Hematology and Oncology in Critical Illness. PEDIATRIC CRITICAL CARE STUDY GUIDE 2012. [PMCID: PMC7178863 DOI: 10.1007/978-0-85729-923-9_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This chapter will focus on a variety of hematologic issues pertinent to the care of critically ill children. This is an area of intense research with the pathophysiology underlying these clinical conditions becoming progressively better understood. This improved understanding has resulted in new therapeutic strategies that are being assessed in multicenter clinical trials. The chapter will begin by describing the incidence and pathophysiologic significance of anemia in the pediatric intensive care unit (PICU) providing a differential diagnosis of the many conditions that may present with anemia in this setting. The chapter will next consider disseminated intravascular coagulation (DIC) focusing on the pathophysiology of a condition that has been associated with much morbidity and mortality. The underlying conditions predisposing to DIC will be detailed as well as a number of treatment options that have been implemented in clinical trials. In addition to DIC, thrombocytopenia may be caused by a number of other clinical conditions important to the pediatric critical care provider. The clinical and prognostic significance of thrombocytopenia will be addressed and a focused differential diagnosis will be provided. Thrombotic disorders are becoming increasingly recognized in children and are a particular concern for the pediatric intensivist. The epidemiology of thromboembolism in children will be reviewed focusing on the conditions most commonly associated with these thromboses. Finally, a chapter on hematologic issues in the critically ill child would not be complete without a discussion of sickle cell disease. Acute chest syndrome, one of the most frequent complications of sickle cell disease resulting in the need for intensive care services, will be discussed in detail.
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Kan E, Levi I, Benharroch D. Alterations in the primary diagnosis of lymphomas pretreated with corticosteroid agents. Leuk Lymphoma 2011; 52:425-8. [PMID: 21323522 DOI: 10.3109/10428194.2010.544049] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Little is known of the role of preliminary corticosteroids in clinical and morphological modifications and in difficulties in reaching a diagnosis in patients with lymphoma. We identified 31 patients who were given steroids before biopsy for primary diagnosis. We looked for the reason for steroid pretreatment, its dose, and duration. We evaluated the difficulty in reaching the primary diagnosis and whether a secondary diagnosis was made. The patients' slides were reviewed to identify secondary histological changes. Our findings suggest a variable effect of prior glucocorticoids on the clinical and histopathological alterations developing in malignant lymphomas, as well as on the complexity of the process of reaching a diagnosis.
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Affiliation(s)
- Elena Kan
- Department of Pathology,Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Kan E, Levy I, Benharroch D. Splenic micronodular T-cell/histiocyte-rich large B-cell lymphoma: effect of prior corticosteroid therapy. Virchows Arch 2009; 455:337-41. [PMID: 19763612 DOI: 10.1007/s00428-009-0830-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 08/16/2009] [Accepted: 08/24/2009] [Indexed: 01/08/2023]
Abstract
We report on three patients who were treated with corticosteroids only prior to the diagnosis of splenic lymphoma. Corticosteroids were administered for different conditions, at different doses, and for various periods of time. The primary diagnosis was splenic micronodular T-cell/histiocyte-rich large B-cell lymphoma in the three cases, and it was reached with variable difficulty. We suggest that the corticosteroid treatment was one of the causes for the complications in reaching a diagnosis. The morphologic appearance of the microscopic splenic nodules was the most variable feature and may possibly reflect the dose and duration of the corticosteroid therapy. However, the histopathologic changes are probably not related with Epstein-Barr virus-induced immunosuppression.
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Affiliation(s)
- Elena Kan
- Department of Pathology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, Beer-Sheva, 84101, Israel
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Perger L, Lee EY, Shamberger RC. Management of children and adolescents with a critical airway due to compression by an anterior mediastinal mass. J Pediatr Surg 2008; 43:1990-7. [PMID: 18970930 DOI: 10.1016/j.jpedsurg.2008.02.083] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 02/24/2008] [Accepted: 02/29/2008] [Indexed: 10/21/2022]
Abstract
This study used retrospective review of patients with critical airway due to compression by an anterior mediastinal mass treated at a single pediatric teaching institution. Diagnostic workup is reviewed with a focus on diagnostic biopsy. Algorithm for streamlining the choice of biopsy technique and minimizing invasive procedures is suggested.
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Affiliation(s)
- Lena Perger
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
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Anghelescu DL, Burgoyne LL, Liu T, Li CS, Pui CH, Hudson MM, Furman WL, Sandlund JT. Clinical and diagnostic imaging findings predict anesthetic complications in children presenting with malignant mediastinal masses. Paediatr Anaesth 2007; 17:1090-8. [PMID: 17897276 PMCID: PMC4400730 DOI: 10.1111/j.1460-9592.2007.02279.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The presence of a mediastinal mass in a child poses significant anesthesia-related risks including death. To optimize outcome clinicians must be able to predict which patients are at highest risk of anesthetic complications. METHODS We conducted a retrospective review of 118 pediatric patients who presented with mediastinal masses. We investigated their medical records for clinical symptoms and signs at presentation and reviewed their chest radiographs, computed tomography scans, and echocardiograms and electrocardiograms when available. We then conducted analyses to identify clinical and diagnostic imaging features associated with anesthesia-related complications. RESULTS Eleven of 117 [9.4%, 95% confidence interval (CI) 4.1-14.7%] patients experienced an anesthesia-related complication. Four preoperative features were significantly associated with anesthetic complications: orthopnea (P = 0.033, odds ratio (OR) 5.31, 95% CI, 1.15-24.56), upper body edema (P = 0.035, OR 8.00, 95% CI, 1.16-55.07), great vessel compression (P = 0.037, OR 5.41, 95% CI, 1.11-26.49), and main-stem bronchus compression (P = 0.044, OR 5.11, 95% CI, 1.05-24.92). The presence of pleural effusion (P = 0.060, OR 4.53, 95% CI, 0.94-21.96) or tracheal compression (P = 0.061, OR 5.09, 95% CI, 0.93-27.81) also appeared to be risk factors. Although the rate of anesthesia-related complications detected in our cohort was comparable with that found in earlier studies, the events were less severe. CONCLUSIONS Patients who present with orthopnea, upper body edema, great vessel compression and main stem bronchus compression are at risk of anesthesia-related complications. The low severity of complications in our series may reflect a combination of factors: use of the least invasive method such as interventional radiology to obtain tissue for diagnosis, completion of a thorough preoperative assessment and minimal anesthesia intervention.
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Affiliation(s)
- Doralina L Anghelescu
- Division of Anesthesiology, St Jude Children's Research Hospital, Memphis, TN 38105-2794, USA.
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