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Elkhatib WY, Saunders H, Helgeson SA, Moss JE. The Use of an Interleukin-6 Inhibitor in Vasoplegic Shock from Severe Systemic Inflammatory Response Syndrome: A Case Report. Indian J Crit Care Med 2021; 25:939-941. [PMID: 34733038 PMCID: PMC8559756 DOI: 10.5005/jp-journals-10071-23943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A 66-year-old Caucasian male with a history of chronic myelomonocytic leukemia (CMML) developed fluid-unresponsive hypotension requiring initiation of four different maximum dosed vasopressors, steroids, and broad-spectrum antibiotics 4 hours following four-vessel coronary artery bypass grafting involving a 150-minute cardiac bypass. Placement of a Swanz-Ganz catheter showed a cardiac output of 7 L/minute with systemic vascular resistance of 571 dynes/sec/cm−5. Over 24 hours, three doses of tocilizumab (interleukin-6 inhibitor) every 8 hours were initiated, plus 250 mg methylprednisolone per 6 hours increment, and then daily thereafter. After the initial dose of tocilizumab, it was possible to wean vasoconstrictors. We have shown for the first time that therapy with tocilizumab is effective in reversing the hemodynamic instability associated with the significant systemic inflammatory response from the “double hit” of CMML and coronary artery bypass grafting with cardiopulmonary bypass as has previously been shown in cytokine release syndrome. How to cite this article: Elkhatib WY, Saunders H, Helgeson SA, Moss JE. The Use of an Interleukin-6 Inhibitor in Vasoplegic Shock from Severe Systemic Inflammatory Response Syndrome: A Case Report. Indian J Crit Care Med 2021;25(8):939–941.
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Affiliation(s)
- Wiaam Y Elkhatib
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States
| | - Hollie Saunders
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States
| | - Scott A Helgeson
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States
| | - John E Moss
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, United States
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Sudden death due to leukostasis in a subject with undiagnosed chronic lymphocytic leukemia. Forensic Sci Med Pathol 2021; 17:693-699. [PMID: 34415512 DOI: 10.1007/s12024-021-00406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
Sudden death due to leukostasis and lymphocyte thrombi in patients with chronic hematologic malignancies is rare. Leukostasis is characterized by highly elevated leukemic cell count and decreased tissue perfusion symptoms, leading to severe complications and even death. Chronic lymphocytic leukemia (CLL) is a chronic lymphoproliferative disorder that shows a highly heterogeneous clinical course, ranging from indolent form to very aggressive disease. Due to its low metabolic and mitotic rate, there is a lower incidence of clinically significant leukostasis in patients with CLL. Two main theories have been proposed in the development of leukostasis: (1) increased blood viscosity due to large leukemic cell populations; (2) high metabolic activity and cytokine production by leukemic cells. Both mechanisms lead to local hypoxic damage.We present a case of a 70-year-old man who died suddenly in the absence of symptoms. Autopsy and histology examinations revealed findings consistent with CLL and diffuse leukostasis involving the major organs' vessels.In the presence of gross and/or microscopic findings suggesting a potential hematologic malignancy, undiagnosed or relapsing hematologic malignancies should be considered in the differential diagnosis of sudden deaths.
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Gaur S, Philipovskiy A, Orazi A. Post-operative hyperleukocytosis and leukostasis as the initial presentation of chronic myelomonocytic leukemia: A case report and review of literature. Leuk Res Rep 2021; 16:100283. [PMID: 34934616 PMCID: PMC8654613 DOI: 10.1016/j.lrr.2021.100283] [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: 04/02/2021] [Revised: 10/22/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022] Open
Abstract
Leukemoid reactions following surgery are commonly caused by infections or tissue injury. Management is directed towards underlying condition and cytoreduction is not indicated. Chronic myelo-monocytic leukemia (CMML) is a clonal hematological malignancy characterized by persistent monocytosis and overlapping features of myelodysplastic and myeloproliferative neoplasms.In this case report we describe a 51-year-old Hispanic female without any significant prior medical history, who underwent a cholecystectomy for calculous cholecystitis. Post-operative course was complicated by hyperleukocytosis leading to splenic infarction and intracranial hemorrhage. Further investigations led to a diagnosis of CMML-2. A literature review of patients with CMML who developed post-operative leukocytosis and leukostasis (POLL) is presented.Case high lights two critical points: Post-operative hyperleukocytosis with leukostasis can be the first presentation of CMML Rapid diagnosis and institution of cytoreductive therapy with hydroxyurea is critical to avoid high morbidity and mortality.
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Jain A, Jain A, Prasad P, Chaudhry S, Sharma M, Khunger JM, Gupta DK, Saluja S. COVID-19 in a patient with chronic myelomonocytic leukemia: a twisting tale. Blood Res 2020; 55:278-281. [PMID: 33380560 PMCID: PMC7784132 DOI: 10.5045/br.2020.2020230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ankur Jain
- Department of Hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Aditi Jain
- Department of Hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Pooja Prasad
- Department of Hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sumita Chaudhry
- Department of Hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Monica Sharma
- Department of Hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Jitender Mohan Khunger
- Department of Hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Dipender Kumar Gupta
- Department of Hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sumita Saluja
- Department of Hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Hus I, Salomon-Perzyński A, Tomasiewicz K, Robak T. The management of hematologic malignancies during the COVID-19 pandemic. Expert Opin Pharmacother 2020; 22:565-582. [PMID: 33342308 DOI: 10.1080/14656566.2020.1849143] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Patients with hematological malignancies have experienced a more severe clinical course of COVID-19 and higher mortality than those with solid tumors and those without cancer. The ongoing pandemic poses many challenges in assuring the correct and timely diagnosis of hemato-oncology patients as well as the optimal treatment.Areas covered: The present paper reviews current data on the incidence and clinical course of COVID-19 in patients with hematological malignancies. A literature review of the MEDLINE database for articles was conducted via PubMed. Publications from December 2019 through September 2020 were scrutinized. The search terms used were SARS-Cov-2 OR COVID-19 in conjunction with hematological malignancies OR leukemia OR lymphoma OR multiple myeloma OR cancer. Recommendations and expert opinions either published or presented on ASH, ASCO, ESMO, NCCN websites were also reviewed.Expert opinion: The COVID-19 pandemic has brought a pressing need to improve the management of patients with hematological malignancies, including establishing prompt diagnoses and providing effective treatment while also minimalizing the risk of SARS-Cov2 infection. The recommendations developed by many organizations based on expert opinions are helpful in making proper decisions. All cancer patients should be advised to get vaccinated against influenza and pneumococcus.
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Affiliation(s)
- Iwona Hus
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.,Department of Clinical Transplantology, Medical University of Lublin, Poland
| | | | | | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz and Copernicus Memorial Hospital, Lodz, Poland
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Melody M, Butts E, Menke D, Landolfo K, Oken K, Sher T, Khurana S. Use of Tocilizumab in Management of Post-Operative Myelomonocytic Leukemoid Reaction. Leuk Res Rep 2020; 14:100228. [PMID: 33240789 PMCID: PMC7672312 DOI: 10.1016/j.lrr.2020.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 11/26/2022] Open
Abstract
Interleukin 6 receptor (IL6R) inhibitor, tocilizumab, has been effectively used in the treatment of cytokine release syndrome in patients receiving chimeric antigen receptor T-cell therapy. Here we present a patient with chronic myelomonocytic leukemia (CMML) who developed a steroid refractory, post-operative myelomonocytic leukemoid reaction (PO-MMLR), effectively treated with tocilizumab. Although, further studies are needed to validate the effectiveness of tocilizumab in management of PO-MMLR, this case serves to provide a new management approach in treatment of this rare but lethal syndrome with no standardized treatment options.
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Affiliation(s)
- Megan Melody
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Emily Butts
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - David Menke
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States
| | - Kevin Landolfo
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Keith Oken
- Department of Cardiology, Mayo Clinic, Jacksonville, FL, United States
| | - Taimur Sher
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Sharad Khurana
- Division of Hematology-Oncology, University of Arizona Cancer Center, Tucson, AZ, United States
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Patnaik MM, Lasho T, Padron E, McCullough K, Al‐kali A, Tefferi A, Zeidan AM, Gangat N, Savona M, Steensma DP, Solary E. Special considerations in the management of patients with myelodysplastic myndrome / myeloproliferative neoplasm overlap syndromes during the SARS-CoV-2 pandemic. Am J Hematol 2020; 95:E203-E208. [PMID: 32356322 PMCID: PMC7267346 DOI: 10.1002/ajh.25853] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 01/08/2023]
Affiliation(s)
| | - Terra Lasho
- Division of HematologyMayo Clinic Rochester Minnesota USA
| | - Eric Padron
- Malignant HematologyMoffitt Cancer Center Tampa Florida USA
| | | | - Aref Al‐kali
- Division of HematologyMayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of HematologyMayo Clinic Rochester Minnesota USA
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine School of Medicine, Yale University and Yale Cancer Center New Haven Conneticut USA
| | - Naseema Gangat
- Division of HematologyMayo Clinic Rochester Minnesota USA
| | - Michael Savona
- Department of Internal MedicineVanderbilt‐Ingram Cancer Center, Vanderbilt University School of Medicine Nashville Tennessee USA
| | - David P. Steensma
- Adult Leukemia Program, Department of Medical OncologyDana‐Farber Cancer Institute Boston Massachusets USA
| | - Eric Solary
- Department of HematologyInstitute Gustave Roussy Paris France
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