Fever in Patients With Cancer

Reactive hemophagocytic lymphohistiocytosis: Epidemiological, clinico-biological and etiological profile

Hemophagocytic lymphohistiocytosis (HLH) is an hyperinflammatory state resulting from increased secretion of proinflammatory cytokines, which are responsible for clinical, biological and cytological manifestations.

OBJECTIVE

The aim of our study is to describe the epidemiological, clinical, biological, etiological and evolutionary profile of HLH in Tunisia.

METHODS

A retrospective study that involved patients, with images of hemophagocytosis in myelograms analyzed at the laboratory of biological hematology of the University Hospital "Hédi-Chaker" of Sfax-Tunisia, followed at these departments: hematology, internal medicine, department of infectious-diseases and department of gastroenterology, (June2017- May2021). First, we identified all patients with hemophagocytosis images. Secondly, we selected the patients who fulfilled the diagnostic criteria of the HLH-2004-score.

RESULTS

Nineteen patients were included in this study. Nine men and 10 women with a mean age of 37.95 years. Fever was present in all patients. Organomegaly was described in 74% of cases. The most frequent cytopenia was anemia (100%). Hypertriglyceridemia was noted in 79% of cases and hyperferritinemia (> 500 ng/mL) was ubiquitous. In myelogram, 68% of patients had slides showing numerous or very numerous images of hemophagocytosis. The infectious pathology was the most common cause of HLH (42%). No cause was found in 10% of cases. The corticosteroid therapy at a dose of 1 mg/kg/day was prescribed in 89% of our patients. The overall evolution was favorable in 58% of cases. The mortality was not associated with the causal pathology (p=0.218).

CONCLUSION

Secondary HLH is likely to be under-recognized, which contributes to its high morbidity and mortality. Early recognition is crucial for any reasonable attempt at curative therapy.

[Infections and fever]

Fever can be due to infectious or noninfectious causes and results from the body's natural response to exogenous or endogenous pyrogens. Laboratory tests including complete blood count, differential blood count, C‑reactive protein, erythrocyte sedimentation rate and procalcitonin do not have sufficient sensitivity and specificity to definitively detect or rule out an infectious (bacterial, viral, parasitic) cause of fever. Blood cultures should be carried out when bacteremic or septic illnesses are suspected. Fever is not always present in infections and can be absent, especially in older and immunocompromised patients. If fever is suspected, core temperatures should be taken, e.g., rectally, orally or invasively. Depending on the clinical situation, infectious causes must be excluded as the most likely cause of an acutely occurring fever. The investigation of long-standing fever (fever of unknown origin, FUO) can be complex and some infectious diseases should first be ruled out, whereby a syndromic classification often helps to clarify the cause of the fever.

A novel method for simultaneous detection of hematological tumors and infectious pathogens by metagenomic next generation sequencing of plasma

BACKGROUND

Metagenomic next-generation sequencing (mNGS) is valuable for pathogen identification; however, distinguishing between infectious diseases and conditions with potentially similar clinical manifestations, including malignant tumors, is challenging. Therefore, we developed a method for simultaneous detection of infectious pathogens and cancer in blood samples.

METHODS

Plasma samples (n = 244) were collected from 150 and 94 patients with infections and hematological malignancies, respectively, and analyzed by mNGS for pathogen detection, alongside human tumor chromosomal copy number variation (CNV) analysis (≥5Mbp or 10Mbp CNV region). Further, an evaluation set, comprising 87 plasma samples, was analyzed by mNGS and human CNV analysis, to validate the feasibility of the method.

RESULTS

Among 94 patients with hematological malignancy, sensitivity values of CNV detection for tumor diagnosis were 69.15 % and 32.98 % for CNV region 5Mbp and 10Mbp, respectively, with corresponding specificities of 92.62 % and 100 % in the infection group. Area under the ROC curve (AUC) values for 5Mbp and 10Mbp region were 0.825 and 0.665, respectively, which was a significant difference of 0.160 (95 % CI: 0.110-0.210; p < 0.001), highlighting the superiority of 5Mbp output region data. Six patients with high-risk CNV results were identified in the validation study: three with history of tumor treatment, two eventually newly-diagnosed with hematological malignancies, and one with indeterminate final diagnosis.

CONCLUSIONS

Concurrent CNV analysis alongside mNGS for infection diagnosis is promising for detecting malignant tumors. We recommend adopting a CNV region of 10Mbp over 5Mbp for our model, because of the lower false-positive rate (FPR).

Chinese multidisciplinary expert consensus on the management of adverse drug reactions associated with savolitinib

Savolitinib is a highly selective mesenchymal-epithelial transition (MET) tyrosine kinase inhibitor (TKI). Based on its significant efficacy shown in clinical studies, savolitinib was conditionally approved for marketing in China on 22 June 2021, for the treatment of advanced non-small cell lung cancer (NSCLC) with MET 14 exon skipping mutation. Additionally, many studies showed that MET TKIs were equally effective in patients with advanced solid tumors with MET gene amplification or MET protein overexpression. Several relevant registered clinical studies are in progress. The most common adverse reactions (ARs) due to savolitinib administration are nausea, vomiting, peripheral edema, pyrexia, and hepatotoxicity. This consensus was developed through two rounds of extensive national surveys involving multidisciplinary experts in China, aiming to guide clinicians to prevent and treat various ARs scientifically, and improve the efficacy of the drug and the quality of life of patients.

Fever As the Exclusive Presenting Symptom in a Case of Colon Cancer

The definition of fever of unknown origin (FUO) has evolved overtime. Most recently, FUO is recognized as fever with uncertain diagnosis despite three days of hospital admission or three or more outpatient visits. Despite diagnostic medical advancements, FUO remains quite a challenge. In the past, infections, such as abscesses, endocarditis, tuberculosis, and complicated urinary tract infections, were common etiologies of FUO; however, at present, such conditions are readily diagnosed. FUO secondary to malignancy has also been decreasing as a result of radiological advancements. Patients with colon cancer usually present with symptoms secondary to the local anatomy of the tumor. Conversely, fever is an uncommon presentation, especially if it is the sole symptom. Here, we report a unique presentation of colon cancer. Our patient only had intermittent fever for one year before being diagnosed with colon cancer. The fever subsided after resection of the tumor. Despite breakthroughs in diagnostic medicine, FUO remains a challenging diagnosis. Practicing clinicians should have a high level of suspicion to rule out underlying malignancy in the setting of recurrent fevers or FUO.

CE: Febrile Neutropenia in the Chemotherapy Patient

ABSTRACT

Febrile neutropenia is a serious complication of chemotherapy treatment and may present as the only clinical sign of infection. If not addressed in a timely manner, it may progress to multisystem organ failure and may be fatal. Initial assessment of fever in those receiving chemotherapy requires prompt administration of antibiotics, ideally within one hour of presentation. Depending on the clinical status of the patient, antibiotic treatment may occur in the inpatient or outpatient setting. Nurses play an important role in the identification and treatment of patients at high risk for febrile neutropenia through assessment and adherence to clinical practice guidelines. In addition, nurses play an active role in patient education regarding risk factors, protective measures, and signs and symptoms of infection in the immunocompromised oncology patient.

Epidemiology and source of infection in cancer patients with febrile neutropenia: an experience from a developing country

BACKGROUND

Febrile neutropenia (FN) is a life-threatening complication that predisposes cancer patients to serious infections. This study aims to describe the epidemiology and source of infection in cancer patients with FN in a tertiary care hospital.

METHODS

A hospital-based retrospective study was conducted in a large tertiary care hospital from January 2020 to December 2021. Data on cancer patients with FN were collected from the hospital information system.

RESULTS

150 cancer patients with FN were identified during the study period. Most patients were males (98; 65.3%), and the mean age of participants was 42.2 ± 16.0 years. Most patients (127; 84.7%) had hematologic malignancies, and acute myeloid leukemia was the most common diagnosis (42; 28%), followed by acute lymphocytic leukemia (28; 18.7%) and Hodgkin's lymphoma (20; 13.3%). Fifty-four (36%) patients had a median Multinational Association for Supportive Care in Cancer (MASCC) scores greater than 21. Regarding the outcome, nine (6%) died, and 141(94%) were discharged. The focus of fever was unknown in most patients (108; 72%). Among the known origins of fever were colitis (12; 8%), pneumonia (8; 5.3%), cellulitis (6; 4%), bloodstream infections (7; 4.6%), perianal abscess (2; 1.3%) and others. The median duration of fever was two days, and the median duration of neutropenia was seven days. Sixty-three (42%) patients had infections: 56 (73.3%) were bacterial, four (2.6%) were viral, two (1%) were fungal and 1 (0.7%) was parasitic. Among the bacterial causes, 50 cases (89.2%) were culture-positive. Among the culture-positive cases, 34 (68%) were gram-positive and 22 (44%) were gram-negative. The most frequent gram-positive bacteria were E. faecalis (9; 18% of culture-positive cases), and the most frequent gram-negative organisms were Klebsiella pneumoniae (5; 10%). Levofloxacin was the most commonly used prophylactic antibiotic (23; 15.33%), followed by acyclovir (1610.7%) and fluconazole in 15 patients (10%). Amikacin was the most popular empiric therapy, followed by piperacillin/tazobactam (74; 49.3%), ceftazidime (70; 46.7%), and vancomycin (63; 42%). One-third of E. faecalis isolates were resistant to ampicillin. Approximately two-thirds of Klebsiella pneumoniae isolates were resistant to piperacillin/tazobactam and ceftazidime. Amikacin resistance was proven in 20% of isolates.

CONCLUSIONS

The majority of patients suffered from hematologic malignancies. Less than half of the patients had infections, and the majority were bacterial. Gram-positive bacteria comprised two-thirds of cases. Therefore, empiric therapy was appropriate and in accordance with the antibiogram of the isolated bacteria.

Clinical characteristics of primary atrial tumor and their diagnostic value: A retrospective study of 10 years

Background

Primary atrial tumors are relatively rare and predominantly benign. However, some atrial tumors may be malignant and are associated with poor outcome. Currently, it is hard to determine the malignance of atrial tumors by preoperative clinical presentation or by echocardiography. We aimed to report the difference in the clinical characteristics of patients with benign and malignant atrial tumor.

Methods

This was a single-center retrospective study. A total of 194 patients with primary atrial tumor admitted to our center between 2012 and 2021 were included. The clinical characteristics of patients with benign and malignant tumor were compared.

Results

Benign and malignant tumor accounted for 93% (n = 180) and 7% (n = 14) of the total patients, respectively. Malignant atrial tumor tended to occur in younger patients (P < 0.05), was more likely to be located at the right atrium (P < 0.05), and tended to attach to the atrial wall or valve instead of the atrial septum. Fever symptoms were more common in patients with malignant tumors than in patients with benign tumors (P < 0.05). Compared to benign tumor, patients with malignant atrial tumor also demonstrated higher rates of fever, lower rates of increasing fibrinogen, increased blood glucose (P < 0.05), significantly longer prothrombin time, and lower prothrombin activity (P < 0.05). Patients with malignant primary atrial tumor had higher mortality rate, tumor metastasis rate, and tumor recurrence rate than patients with benign primary atrial tumor (P < 0.05).

Conclusion

We compared the clinical characteristics of patients with benign and malignant atrial tumor. These findings provide valuable information to preoperatively determine the malignance of atrial tumor and thus guide surgical treatment.

Development of a Core Body Thermometer Applicable for High-Temperature Environment Based on the Zero-Heat-Flux Method

Monitoring core body temperature (CBT) allows observation of heat stress and thermal comfort in various environments. By introducing a Peltier element, we improved the zero-heat-flux core body thermometer for hot environments. In this study, we performed a theoretical analysis, designed a prototype probe, and evaluated its performance through simulator experiments with human subjects. The finite element analysis shows that our design can reduce the influence of external temperature variations by as much as 1%. In the simulator experiment, the prototype probe could measure deep temperatures within an error of less than 0.1 °C, regardless of outside temperature change. In the ergometer experiment with four subjects, the average difference between the prototype probe and a commercial zero-heat-flux probe was +0.1 °C, with a 95% LOA of -0.23 °C to +0.21 °C. In the dome sauna test, the results measured in six of the seven subjects exhibited the same trend as the reference temperature. These results show that the newly developed probe with the Peltier module can measure CBT accurately, even when the ambient temperature is higher than CBT up to 42 °C.

Emerging Trends in Radionuclide Imaging of Infection and Inflammation in Pediatrics: Focus on FDG PET/CT and Immune Reactivity

The most common indication for ¹⁸F-FDG PET/CT is tumor imaging, which may be performed for initial diagnosis, staging, therapeutic response monitoring, surveillance, or suspected recurrence. In the routine practice of pediatric nuclear medicine, most infectious, inflammatory, and autoimmune processes that are detected on ¹⁸F-FDG PET/CT imaging - except for imaging in fever or inflammation of unknown origin - are coincidental and not the main indication for image acquisition. However, interpreting these "coincidental" findings is of utmost importance to avoid erroneously attributing these findings to a neoplastic process. We review the recent literature on fever of unknown origin as well as inflammation of unknown origin in pediatrics and then focus on the ¹⁸F FDG PET/CT imaging findings seen in two specific entities with increased immune reactivity: hemophagocytic lymphohistiocytosis syndrome and the immune-related adverse events associated with checkpoint inhibitors. We will subsequently close with two sections highlighting related topics and relevant references for further reading.

Single-Center Analysis of Pegfilgrastim-induced Aortitis Using a Drug Prescription Database and CT Findings

Background Pegfilgrastim-induced aortitis is a rare but serious adverse event in patients undergoing anticancer therapy with granulocyte colony-stimulating factor analogs. Despite previous case series and systemic reviews, the exact incidence, clinical presentation, and CT manifestations of pegfilgrastim-induced aortitis remain unclear. Purpose To clarify the incidence and clinicoradiologic characteristics of pegfilgrastim-induced aortitis. Materials and Methods Pegfilgrastim administration records from January 2015 to March 2021 were retrospectively collected from the drug prescription database of a single center and were matched with the relevant findings in the CT database. Corresponding CT images within 6 months were available for a total of 1462 doses of pegfilgrastim in 674 patients. Four radiologists reviewed the CT images for the presence of aortitis in two steps. Clinical information and the distribution of aortitis on CT images were examined for patients with a diagnosis of pegfilgrastim-induced aortitis. Results Pegfilgrastim-induced aortitis was observed in 18 of 674 patients (mean age, 62 years ± 13 [SD]; 424 men), resulting in incidence rates of 2.7% per patient (95% CI: 1.6, 4.2) and 1.2% per dose (95% CI: 0.7, 1.9). The most common original primary malignancies were esophageal cancer (n = 10, 9%), breast cancer (n = 3, 4%), and pancreatic cancer (n = 2, 2%). The most common anticancer drugs used at onset were 5-fluorouracil, cisplatin, and docetaxel. Seven cases were symptomatic, while the remaining 11 (61%) were asymptomatic. CT findings indicated that aortitis involved branches of the aortic arch in 13 cases (72%), aortic arch in 10 cases (56%), and abdominal aorta in two cases (11%). Conclusion Pegfilgrastim-induced aortitis may be more prevalent than previously reported and may be more common in patients with esophageal cancer and those who received 5-fluorouracil, cisplatin, and docetaxel as anticancer drugs. The findings also suggest that pegfilgrastim-induced aortitis is often characterized by aortic arch and proximal branch involvement at CT. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Krinsky in this issue.

Fever as a first presentation of castration-resistant prostate cancer: A case report

RATIONALE

Cancer is a well-recognized cause of fever, which is related to cytokines produced by malignant cells. Prostate cancer presenting with fever and other inflammatory markers as a paraneoplastic syndrome rarely occurs.

PATIENTS CONCERNS AND DIAGNOSES

We describe the case of high fever and lower-urinary tract symptoms that progressed 1 month prior to presentation. A 78-year-old man had been diagnosed with prostate cancer 8 months ago. He received androgen deprivation therapy with leuprolide acetate 22.5 mg for every 3 months. Castration-resistant prostate cancer was diagnosed due to elevated prostate specific antigen (1639 ng/mL) and cancer fever.

INTERVENTION

The patient received docetaxel-based systemic chemotherapy 50 mg/mm2 biweekly. Naproxen 500 mg was administered twice a day.

OUTCOMES

After one cycle of systemic chemotherapy, the patient had no major side effects, no more fever was observed, and the systemic condition improved.

CONCLUSION

Differentiating cancer-related fever from infection-related fever is important for appropriate patient management. In this case, fever appeared as the first symptom of castration-resistant prostate cancer and was managed by naproxen and resolved with systemic chemotherapy.

Vincristine induced fever in a child with embryonal rhadbomyosarcoma

INTRODUCTION

Febrile episodes in oncology is common are mostly of infectious etiology requiring repeated investigations and escalation of antibiotics. But, drug induced fever occur more often than we think in oncological set-up.

CASE REPORT

A 5 year old male child with rhabdomyosarcoma, developed high grade fever spikes following Vincristine monotherapy. Infective etiology work up was negative and the fever responded to corticosteroids.

MANAGEMENT AND OUTCOME

He was treated with corticosteroids as premedication considering vincristine induced fever. The further courses of VCR- monotherapy were uneventful with steroids as premedication.

DISCUSSION

We present the case of vincristine induced fever in a child with embryonal rhabdomyosarcoma. Clinician's should consider drug induced fever at appropriate conditions, to avoid leading to antibiotic resistance.

Treatment decision for cancer patients with fever during the coronavirus disease 2019 (COVID-19) pandemic

Background

Cancer patients have been disproportionally affected by the coronavirus disease 2019 (COVID-19) pandemic, with high rates of severe outcomes and mortality. Fever is the most common symptom in COVID-19 patients. During the COVID-19 pandemic, physicians may have difficulty in determining the cause of fever (COVID-19, another infection, or cancer fever) in cancer patients. Furthermore, there are no specific guidelines for managing cancer patients with fever during the COVID-19 pandemic. Thus, this study evaluated the clinical characteristics and outcomes of cancer patients with fever during the COVID-19 pandemic.

Methods

This study retrospectively reviewed the medical records of 328 cancer patients with COVID-19 symptoms (fever) admitted to five hospitals in Daegu, Korea from January to October 2020. We obtained data on demographics, clinical manifestations, laboratory test results, chest computed tomography images, cancer history, cancer treatment, and outcomes of all enrolled patients from electronic medical records.

Results

The most common COVID-19-like symptoms were fever (n=256, 78%). Among 256 patients with fever, only three (1.2%) were diagnosed with COVID-19. Most patients (253, 98.8%) with fever were not diagnosed with COVID-19. The most common solid malignancies were lung cancer (65, 19.8%) and hepatobiliary cancer (61, 18.6%). Twenty patients with fever experienced a delay in receiving cancer treatment. Eighteen patients discontinued active cancer treatment because of fever. Major events during the treatment delay period included death (2.7%), cancer progression (1.5%), and major organ dysfunction (2.7%).

Conclusion

Considering that only 0.9% of patients tested for COVID-19 were positive, screening for COVID-19 in cancer patients with fever should be based on the physician’s clinical decision, and patients might not be routinely tested.

Management and Thinking on the Treatment of Cancer Patients During the COVID-19

Coronavirus disease-2019 (COVID-19) has spread rapidly around the world and has become a public health emergency of international concern. The weekly epidemiological report issued by the WHO pointed out that new coronavirus variants have appeared in 131 countries and regions, which demonstrates that the current epidemic situation is still severe. As of now, the severe acute respiratory syndrome coronavirus (SARS-CoV-2) has been widespread worldwide for more than one year and poses a serious threat to the health of vulnerable groups such as those with malignancies, the elderly, and the immunocompromised. Compared with the general population, cancer patients with COVID-19 infection are more likely to have serious clinical adverse events, leading to higher mortality. There is no doubt that during the COVID-19 epidemic, whether it is with regards to how to prevent infection or how to continue anti-tumor treatment, cancer patients are in a difficult situation. Meanwhile, an international patient with malignant Hodgkin's lymphoma who was cured after being infected with the new coronavirus surprised us, and it inspires more scientists to explore the relationship between infection, immunity, and tumors. Relevantly, through multi-disciplinary discussion, scientists put forward more new perspectives on the treatment of future tumors and the management of SARS-CoV-2 diseases. In this review, the impact of COVID-19 on cancer patients is discussed in detail and the recommendations for the diagnosis, treatment and management of cancer patients will be put forward under the challenge of the COVID-19 epidemic. Furthermore, the safety and effectiveness of the SARS-CoV-2 vaccine will be discussed, and we will also put forward our insights on cancer immunity.

Temperature Plays an Essential Regulatory Role in the Tumor Immune Microenvironment

In recent years, emerging immunotherapy has been included in various malignant tumor treatment standards. Temperature has been considered to affect different pathophysiological reactions such as inflammation and cancer for a long time. However, in tumor immunology research, temperature is still rarely considered a significant variable. In this review, we discuss the effects of room temperature, body temperature, and the local tumor temperature on the tumor immune microenvironment from multiple levels and perspectives, and we discuss changes in the body's local and whole-body temperature under tumor conditions. We analyze the current use of ablation treatment-the reason for the opposite immune effect. We should pay more attention to the therapeutic potential of temperature and create a better antitumor microenvironment that can be combined with immunotherapy.

Can we truly diagnose adult secondary hemophagocytic lymphohistiocytosis (HLH)? A critical review of current paradigms

The HLH-2004 criteria were initially conceived as inclusion criteria for a clinical trial investigating therapy for (largely primary) pediatric hemophagocytic lymphohistiocytosis (HLH). These criteria have since been extrapolated to diagnose adult secondary HLH despite their questionable generalizability. It remains unclear whether these diagnostic criteria are truly applicable among adult secondary cases, and rigorous evidence for their use among such patients is lacking. This review critically examines the utility of the HLH-2004 criteria for the diagnosis of adult secondary HLH. It is framed as a reappraisal of each of the criteria's individual components, with an assessment of the relevance of, and/or evidence regarding, each. There are clear limitations to these criteria as they apply to adult secondary HLH, however they may help guide our understanding of the disease to some extent. Some new paradigms are emerging for the diagnosis of adult secondary HLH, however these too are limited by the difficulties inherent in formulating specific criteria for a very non-specific syndrome, which lacks any single gold-standard diagnostic test.

Hypogonadism and cancer survivorship

PURPOSE OF REVIEW

Hypogonadism is highly prevalent among not only patients with a history of prior treatment for cancer, but also among those patients with a new oncologic diagnosis who have not yet received any cancer therapy. Hypogonadism can cause a wide array of signs and symptoms including: deceased muscle mass; increased fat mass; decreased energy, mood, and overall sense of well being; diminished bone mineral density; infertility; and impaired libido and sexual function. This purpose of this manuscript is to review the mechanisms by which cancer and oncologic treatment regimens can adversely affect the hypothalamic pituitary gonadal axis, resulting in hypogonadism. Risks and benefits associated with the treatment of testosterone deficiency are also discussed, which are important considerations for clinicians caring for affected patients.

RECENT FINDINGS

Hypogonadism has a high prevalence in the setting of cancer and is an important survivorship issue. Recent randomized controlled trials confirm testosterone's therapeutic benefits in terms of sexual function, mood body composition, and bone health, but the specific benefits in terms of quality of life are less clear.

SUMMARY

More prospective studies are needed to further delineate the risks, benefits, and overall outcomes of testosterone replacement therapy in patients with cancer and cancer survivors.

Cabozantinib as the causative agent of high-grade fever in a patient with a background of metastatic clear cell renal cell carcinoma: a case report

Background

Fever, as an adverse event, is well documented in a wide array of drugs including multiple tyrosine kinase inhibitors however, it is not a previously well described consequence of the novel multi-targeted tyrosine kinase inhibitor, cabozantinib.

Case presentation

In this paper we document the first detailed review of high-grade fevers in a 54 year old male (Caucasian) with a background of metastatic clear cell renal cell carcinoma recently commenced on cabozantinib. After detailed investigation, we exclude infection and other common causes of fever as the causative agent and further, definitively resolve the recurrent fever by ceasing cabozantinib and starting a short course of oral corticosteroids.

Conclusions

We have demonstrated that cabozantinib should always be considered in the aetiology of high-grade fever in relevant patients. Further, we demonstrate that temporary cessation of cabozantinib and a course of short-term steroids can induce resolution of fever and allow for recommencement of cabozantinib safely thereafter.

Systematic Assessment of Risk of Fever in Solid Tumor Patients Treated With PD-1/PD-L1 Inhibitors: A Systematic Review and Meta-Analysis

Purpose: Drug-induced fever is frequently reported in cancer patients treated with anti-programmed cell death 1 (PD-1)/programmed cell death ligand 1 (PD-L1), and stoppage of the offending agent is the management of choice. However, given the complex management of cancer patients, this needs to be carefully studied. Therefore, we conducted a meta-analysis to estimate the risk of fever associated with anti-PD-1/PD-L1 in cancer patients.

Methods: From May 2010 to 2020, an electronic search was conducted through PubMed for relevant studies. All clinical trials reporting fever in cancer patients treated with PD-1/PD-L1 inhibitors were included, while other designs were excluded. A manual search was also conducted to search for relevant articles. Outcomes included the risk of pyrexia and febrile neutropenia in the overall population and based on the grade of fever (all grades vs. grades 3–5). The Newcastle–Ottawa Scale was used to assess the quality of included studies.

Results: Thirty-one articles, involving 27 clinical trials and 15,867 participants, were included. The increased risk of pyrexia for all grades is only found when PD-1/PD-L1 plus cytotoxic T lymphocyte-associated protein 4 (CTLA-4) was compared to CTLA-4 [odds ratio (OR) = 2.48, 95% CI: 1.17, 5.23]. The risk of febrile neutropenia for all-grade fever was significantly lower in the PD-1/PD-L1 group compared to that of chemotherapy alone (OR = 0.02, 95% CI: 0.01, 0.05). A similar trend in the risk of febrile neutropenia was also found for grades 3–5 (OR = 0.02, 95% CI: 0.01, 0.05).

Conclusion: The increased risk of pyrexia for all grades could only be found when PD-1/PD-L1 plus CTLA-4 was compared with CTLA-4. Meanwhile, compared to chemotherapy, PD-1/PD-L1 inhibitors reduced the risk of febrile neutropenia.

Management strategy for cancer patients in the context of the COVID-19 epidemic

Coronavirus infection 2019 (COVID-19) has emerged a very dangerous infectious disease that occurs as an acute respiratory viral infection with complications, including pneumonia with acute respiratory distress syndrome or respiratory failure with a risk of death. As already confirmed, COVID-19 is caused by the new severe acute respiratory syndrome-2 coronavirus (SARS-CoV-2). We describe our strategy for the management of cancer patients based on the experience of the medical staff of the Regional Clinical Oncology Center of the Republic of Bashkortostan. We hope this can serve as a guide for oncologists to provide emergency care in the context of the COVID-19 epidemic.

Computer-aided biomarker discovery for precision medicine: data resources, models and applications

Biomarkers are a class of measurable and evaluable indicators with the potential to predict disease initiation and progression. In contrast to disease-associated factors, biomarkers hold the promise to capture the changeable signatures of biological states. With methodological advances, computer-aided biomarker discovery has now become a burgeoning paradigm in the field of biomedical science. In recent years, the 'big data' term has accumulated for the systematical investigation of complex biological phenomena and promoted the flourishing of computational methods for systems-level biomarker screening. Compared with routine wet-lab experiments, bioinformatics approaches are more efficient to decode disease pathogenesis under a holistic framework, which is propitious to identify biomarkers ranging from single molecules to molecular networks for disease diagnosis, prognosis and therapy. In this review, the concept and characteristics of typical biomarker types, e.g. single molecular biomarkers, module/network biomarkers, cross-level biomarkers, etc., are explicated on the guidance of systems biology. Then, publicly available data resources together with some well-constructed biomarker databases and knowledge bases are introduced. Biomarker identification models using mathematical, network and machine learning theories are sequentially discussed. Based on network substructural and functional evidences, a novel bioinformatics model is particularly highlighted for microRNA biomarker discovery. This article aims to give deep insights into the advantages and challenges of current computational approaches for biomarker detection, and to light up the future wisdom toward precision medicine and nation-wide healthcare.

Febrile Temperature Critically Controls the Differentiation and Pathogenicity of T Helper 17 Cells

Fever, an evolutionarily conserved physiological response to infection, is also commonly associated with many autoimmune diseases, but its role in T cell differentiation and autoimmunity remains largely unclear. T helper 17 (Th17) cells are critical in host defense and autoinflammatory diseases, with distinct phenotypes and pathogenicity. Here, we show that febrile temperature selectively regulated Th17 cell differentiation in vitro in enhancing interleukin-17 (IL-17), IL-17F, and IL-22 expression. Th17 cells generated under febrile temperature (38.5°C-39.5°C), compared with those under 37°C, showed enhanced pathogenic gene expression with increased pro-inflammatory activities in vivo. Mechanistically, febrile temperature promoted SUMOylation of SMAD4 transcription factor to facilitate its nuclear localization; SMAD4 deficiency selectively abrogated the effects of febrile temperature on Th17 cell differentiation both in vitro and ameliorated an autoimmune disease model. Our results thus demonstrate a critical role of fever in shaping adaptive immune responses with implications in autoimmune diseases.

Neutropenic Fever

Neutropenia is defined as an abnormally low absolute neutrophil count (ANC) and can be further delineated as severe or profound (see below). Recipients of chemotherapy will often have a decreased ANC leading to an increased risk of infections specifically from bacterial sources. Neutropenia traditionally is risk stratified based on duration and depth of neutropenia. Recipients of chemotherapy for acute myelogenous leukemia (AML) and stem cell transplants (SCTs) often are deemed as having high risk neutropenia due to significant depth and duration of neutropenia. The mortality associated with febrile neutropenia is up to 11%, and can be as high as 50% in the setting of severe sepsis or septic shock. By risk stratifying neutropenia and the resultant neutropenic fever, the goal is to decrease the resultant morbidity and mortality (Taplitz et al., J Clin Oncol 36:3043–3054).

Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician

: The initial management of the hematology patient in a critical state is crucial and poses a great challenge both for the hematologist and the intensive care unit (ICU) physician. After years of clinical practice, there is still a delay in the proper recognition and treatment of critical situations, which leads to late admission to the ICU. There is a much-needed systematic ABC (Airway, Breathing, Circulation) approach for the patients being treated on the wards as well as in the high dependency units because the underlying hematological disorder, as well as disease-related complications, have an increasing frequency. Focusing on score-based decision-making on the wards (Modified Early Warning Score (MEWS), together with Quick Sofa score), active sepsis screening with inflammation markers (C-reactive protein, procalcitonin, and presepsin), and assessment of microcirculation, organ perfusion, and oxygen supply by using paraclinical parameters from the ICU setting (lactate, central venous oxygen saturation (ScVO2), and venous-to-arterial carbon dioxide difference), hematologists can manage the immediate critical patient and improve the overall outcome.

Pulmonary sarcoidosis as a cause of intermittent fever of unknown origin in a hemodialysis patient with renal cell carcinoma: A case report and literature review

Hemodialysis patients have weakened immune systems and can exhibit fever due to various causes. Herein, we describe the case of a 61-year-old hemodialysis patient who exhibited intermittent low-grade fever after a pacemaker had been implanted 2 months before due to sick sinus syndrome. She had a medical history of subcutaneous sarcoidosis and uveitis. Active pulmonary sarcoidosis was diagnosed based on elevated soluble interleukin-2 receptor, elevated lysozyme level, and gallium-67 scintigraphy uptake in hilar and mediastinal lymph nodes. She was also diagnosed with renal cell carcinoma via contrast computed tomography. However, because her C-reactive protein level remained normal, the possibility of neoplastic fever was considered low. After the initiation of prednisolone administration, her fever gradually disappeared. Her serum soluble interleukin-2 receptor and lysozyme level improved in parallel with the enlargement of the mediastinal lymph node and gallium-67 scintigraphy uptake.