Rheumatological adverse events secondary to immune checkpoint inhibitors

The first experiences with a group of drugs called immune checkpoint inhibitors for the treatment of cancer were described in 2010. They are currently used in many tumours, with successful survival outcomes but a new profile of adverse events. This new spectrum of immune-mediated toxicities includes an exaggerated inflammatory response of T lymphocyte and the development of autoimmune diseases or similar pathologies. Of these, of particular note are the rheumatological toxicities. This review aims to alert internists and rheumatologists to their recognition and clinical management.

Determinants of the clinical presentation of acute coronary syndromes

INTRODUCTION

Two clinical presentations of acute coronary syndrome (ACS) have been defined: ST- segment elevation ACS (STEACS) or non-ST-segment elevation ACS (NSTEACS). The mechanism that determines the clinical presentation of ACS is not clearly understood. The aim of this study was to define the association between cardiovascular risk factors and other clinical variables with the clinical presentation of ACS as STEACS or NSTEACS.

METHODS

We analyzed data of patients prospectively included in the Epi-Cardio Registry with a diagnosis of ACS from April 2006 to April 2018. A total of 10 019 patients were included in the study.

RESULTS

In the multivariate analysis, male sex (OR 1.5) and active smoking (OR 1.71) were positively associated with STEACS presentation. Conversely, hypertension (OR 0.71), dyslipidemia (OR 0.74), age (OR 0.97 per quintile), history of myocardial infarction (OR 0.57), chronic angina (OR 0.44), presence of comorbidities (OR 0.64), and extension of coronary heart disease (OR 0.84) were negatively associated with STEACS. Women differed from men by presenting a higher incidence of NSTEACS, due to a greater proportion of ACS without obstructive coronary heart disease.

CONCLUSION

Some cardiovascular risk factors and other clinical variables are independently associated with the presentation of ACS as ST EACS or NSTEACS. These findings confirm the influence of risk factors and clinical history on the pathophysiology, clinical and electrocardiographic presentation of ACS.

[Pembrolizumab-induced gastritis with PDL1 histological expression]

Immune-mediated gastritis is a rare adverse effect in patients treated with immune checkpoint inhibitors. We present a patient with a diagnosis of cervical carcinoma under treatment with pembrolizumab who was admitted with nausea, vomiting and weight loss; an endoscopy revealed a ulcerated lesion covered by mucus in the antrum and gastric body. The biopsy revealed extensive denudation of the gastric mucosa with fibrin leukocyte reaction. Into the lamina propria, an increased lymphocytic and polymorphonuclear inflammatory infiltrate was observed. Immunohistochemistry confirmed positivity for PDL1 (clone SP2630) and combined positive score of 35%, with a relative contribution of epithelial cells of 25% and inflammatory cells of 10%. After three weeks with 30 mg meprednisone, a new endoscopy revealed a stomach with clear mucus content; fundus and body without lesions, and an antrum with congestive mucosa and multiple superficial ulcers covered by fibrin. Diagnostic and therapeutic aspects of immune-mediated gastritis are described.

Impact of high neutrophil-to-lymphocyte ratio on survival in hospitalized cancer patients with COVID-19

Neutrophil-to-lymphocyte ratio (NLR) has been studied as a prognostic factor for mortality in COVID-19 patients. Our study aimed to evaluate the association between NLR at COVID-19 diagnosis and survival during the following 90 days in hospitalized patients with solid cancer. Between May 2020 and June 2021, 120 patients were included in a retrospective cohort study. Univariable analysis showed patients with an NLR > 8.3 were associated with an increased risk of death (HR: 4.34; 95% CI: 1.74-10.84) compared to patients with NLR < 3.82 and with NLR ≥3.82 and ≤8.30 (HR: 2.89; 95% CI: 1.32-6.36). Furthermore, on multivariable analysis, NLR > 8.30 independently correlated with increased mortality. In patients with solid malignancies with COVID-19, an NLR > 8.3 is associated with an increased risk of death.

Hypothyroid cardiomyopathy: A reversible phenocopy of hypertrophic cardiomyopathy

We present the case of a 46-year-old patient with hypothyroidism secondary to Hashimoto's thyroiditis who was admitted with decompensation in the form of myxedema. A 2-D echocardiogram shows a septal asymmetric hypertrophy, with low-voltage QRS complex in the ECG and a bull's-eye map of longitudinal strain with preserved apical strain with reduction of mid and basal strain that results in "cherry on the top" pattern, similar to the most frequent phenocopy of hypertrophic cardiomyopathy, as is the cardiac amyloidosis, and that, unlike this pathology, reverted after the patient reached the euthyroid state.

[Descriptive analysis of 4776 patients admitted to medical clinic services for COVID-19. Results of the Argentine Multi-Center Registry - REMA-COVID-19]

A multicenter registry that included adults hospitalized for COVID-19 was carried out in various provinces of Argentina, from March to October 2020. The objectives were to describe the epidemiological characteristics, clinical manifestations, treatments, complications and risk factors, need for admission to critical care units and mortality. The registry included information on 4776 patients in 37 health centers in Argentina. Of them, 70.2% came from the city of Buenos Aires and from Buenos Aires Province; 52.3% were men. The mean age was 56 years (SD 20.3). Of them, 13.1% stated that they were health personnel. The median time of symptoms at the time of hospitalization was 3 days (CI 1-6). The most frequent comorbidities were hypertension in 32.4% and diabetes mellitus in 15.8%. The most frequent symptoms were: cough 58%, odynophagia 23.3%, myalgia 20.5% and fever / low-grade fever 19.9%. The hospital stay had a median of 8 days (CI 4-15). A 14.8% of the patients required critical care, while 3.2% who also required it, were not transferred to a closed unit due to adequacy of the therapeutic effort. The most frequent complications in critical care were: cardiovascular events (54.1%), septic shock (33.3%), renal failure (9.7%) and pneumonia associated with mechanical ventilation (12.5%). Overall mortality was 12.3%. Old age, dementia and COPD behaved as independent predictors of mortality (p < 0.001, 0.007 and 0.002 respectively) in the multivariate analysis.

[Adverse drug reactions associated with immune checkpoint inhibitors]

The management of patients with immune-related adverse events (irAEs) frequently demands a multidisciplinary approach. We reviewed the causes and clinical course of medical visits and admissions at the Instituto Alexander Fleming due to irAEs between September 2015 and July 2019. Demographic data, diagnosis, toxicity and its severity, requirement of admission, treatment, mortality, and evaluation of the re-administration of immunotherapy were collected. We found 124 irAEs in 89 patients. Sixty-eight of them received monotherapy (76.4%) and 21 (23.6%) combination of drugs. Cutaneous manifestations were the most frequent cause of irAEs, followed by general manifestations, endocrine dysfunctions (hypothyroidism the most frequent), colitis, pneumonitis, neurologic disorders, and hepatitis. In 26 adverse events (in 25 patients), severity grade was = 3. Fifteen were admitted and 6 required ICU admission. One patient died. Thirty-four received glucocorticoids, 12 of them by intravenous route. One patient received mycophenolate and one IVIG. In 20, the treatment was discontinued; 8 were re-exposed, with definitive discontinuation in one patient. In this case series we report our experience in the diagnosis and management of adverse reactions related to a family of drugs whose use has grown in recent years.

[Clinical outcomes in cancer patients hospitalized with COVID-19]

Cancer patients are exposed to more complications from COVID-19 than non-cancer patients. We report a cohort of 74 cancer patients (87.8% with solid neoplasia and 12.2% with hematological diseases) with COVID-19 infection admitted to a tertiary medical cancer center in Argentina. Pulmonary infiltrates were diagnosed at admission in 78.3% (N = 58) of the cases. COVID-19 infection was hospital-acquired in 20 (27.0%) patients. Thirty-nine patients (52.7%) received anticancer therapy within the 30 days prior to COVID-19 diagnosis; one was on radiation therapy. Twenty-four (32.4%) patients were admitted in the intensive care unit (ICU) and 18 (75.0%) required mechanical ventilation. All cause in-hospital mortality was 32.4% (N = 24) and ICU mortality was 62.5% (N = 15). Mortality under mechanical ventilation was 72.2% (N = 13). In the univariate analysis age, neutrophil count, neutrophil/lymphocyte index, D-dimer, ferritin, smoking, and nosocomial acquired infection were associated with in-hospital mortality. There were no statistically significant differences in mortality related to disease stage for solid tumors, neither cancer treatment within 30 days of COVID-19 diagnosis. Age and smoking were associated with mortality in the multivariate analysis. The adjusted odds ratios (95 CI) for age = 65 years and smoking were 8.87 (1.35-58.02) and 8.64 (1.32 - 56.64), respectively. Our experience can be useful for other institutions that assist cancer patients during the pandemic.

[Argentine Intersociety Consensus on Urinary Infection 2018-2019 - Part II]

The second part of the Inter-Society Argentine Consensus on Urinary Tract Infection (UTI) includes the analysis of special situations. In patients with urinary catheter, urine culture should be requested only in the presence of UTI symptomatology, before instrumentation of the urinary tract, or as a post-transplant control. The antibiotics recommended for empirical treatment in patients without risk factors are third-generation cephalosporins or aminoglycosides. UTIs associated with stones are always considered complicated. In case of obstruction with urosepsis, an emergency drainage should be performed via a percutaneous nefrostomy or ureteral stenting. In patients with stents or ureteral prostheses, such as double J catheters, empirical treatment should be based on epidemiology, prior antibiotics, and clinical status. Before the extracorporeal lithotripsy procedure, bacteriuria should be investigated and antibiotic prophylaxis should be administered in case of positive result, according to the antibiogram. First generation cephalosporins or aminoglycosides are valid alternatives. The use of antibiotic prophylaxis with first-generation cephalosporins or aminoglycosides before percutaneous nephrolithotomy is recommended. Transrectal prostatic biopsy can be associated with infectious complications, such as UTI or acute prostatitis, mainly due to Escherichia coli or other enterobacteria. In patients without risk factors for multiresistant bacteria and negative urine culture, prophylaxis with intravenous amikacin or ceftriaxone is recommended. In patients with positive urine culture, prophylaxis will be performed according to the antibiogram, from 24 hours before to 24 hours post-procedure. For the targeted treatment of post-transrectal biopsy prostatitis, carbapenems for 3-4 weeks are the treatment of choice.

[Consenso Argentino Intersociedades de Infección Urinaria 2018-2019 - Parte I]

The Argentine Society of Infectious Diseases and other scientific societies have updated these recommendations based on data on urinary tract infections in adults obtained from a prospective multicenter study conducted in Argentina during 2016-2017. Asymptomatic bacteriuria should be treated only in pregnant women, who should also be systematically investigated; the antibiotics of choice are nitrofurantoin, amoxicillin, clavulanic/amoxicillin, cephalexin and trimethoprim-sulfamethoxazole. In procedures involving injury to the urinary tract with bleeding, it is recommended to request urine culture and, in the presence of bacteriuria, antimicrobial treatment according to sensitivity should be prescribed from immediately before up to 24 hours after the intervention. In women, cystitis can be treated with nitrofurantoin, cephalexin or fosfomycin, while trimethoprim-sulfamethoxazole and fluoroquinolones are not recommended; pyelonephritis can be treated with ciprofloxacin, cefixime or cephalexin in ambulatory women or ceftriaxone, cefazolin or amikacin in those who are hospitalized. In men, urinary tract infections are always considered complicated; nitrofurantoin or cephalexin are recommended for 7 days, alternatively fosfomycin should be given in a single dose. In men, ciprofloxacin, ceftriaxone or cefixime are suggested for pyelonephritis on ambulatory treatment whereas ceftriaxone or amikacin are recommended for hospitalized patients. Acute bacterial prostatitis can be treated with ceftriaxone or gentamicin. Fluoroquinolones were the choice treatment for chronic bacterial prostatitis until recently; they are no longer recommended due to the increasing resistance and recent concerns regarding the safety of these drugs; alternative antibiotics such as fosfomycin are to be considered.

[Malignant syphilis in a patient with HIV infection]

Malignant syphilis occurs frequently in patients infected with human immunodeficiency virus (HIV) and presents with cutaneous nodular lesions that tend to ulcerate. Non caseating granulomas are among the most conspicuous histopathological findings and require differential diagnosis with other infectious and non-infectious granulomatous conditions. The evolution of the disease is usually favourable with penicillin treatment. We present the case of an HIV-positive patient who meets diagnostic criteria for malignant syphilis and alert on this infrequent granulomatous entity.

Severe hypokalemia due to a possible drug-drug interaction between vinblastine and antiretrovirals in a HIV-infected patient with Hodgkin's lymphoma

A 60-year-old HIV-1 infected woman on antiretroviral therapy (emtricitabine/tenofovir, and ritonavir-boosted atazanavir) developed Hodgkin's lymphoma. The patient initiated ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) chemotherapy and presented with neutropenia and severe hypokalemia. Hypokalemia was considered as part of a proximal tubular renal dysfunction, and other causes of hypokalemia were excluded. Due to suspicion of drug--drug interactions between antiretrovirals and vinblastine, ritonavir-boosted atazanavir was switched to dolutegravir and the patient continued emtricitabine/tenofovir. In the subsequent ABVD cycles, no neutropenia or hypokalemia were observed. Vinblastine is metabolized by the hepatic P450 cytochrome isoenzyme CYP3A4, therefore, concomitant administration with protease inhibitors may increase plasma levels of vinblastine. Vinblastine is also a substrate and inhibitor of multidrug resistance-associated protein 2 (MRP2) transporter in the proximal renal tubule. Inhibition of this renal transporter could increase tenofovir renal toxicity. Our hypothesis is that the hypokalemia could be a result of a tenofovir-mediated tubular damage triggered by the increased vinblastine serum levels secondary to a CYP3A4 inhibition by ritonavir. To the best of our knowledge, this is the first report of severe hypokalemia and proximal tubular renal dysfunction as a result of a possible drug-drug interaction between vinblastine, tenofovir and ritonavir-boosted atazanavir.

[ASIA syndrome: breast implant and Still's disease]

Connective tissue diseases associated with silicone breast implants have been widely discussed. In the last decade, siliconosis has been included in the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) next to Gulf War syndrome, macrophage myofascitis and postvaccination phenomena. The ASIA syndrome may appear as lupus, rheumatoid arthritis, or more rarely, as adult Still's disease. We discuss the case of a patient with prolonged fever and clinical criteria for ASIA and Still's disease. The prostheses were resected and pathology showed absence of breast implant associated anaplastic lymphoma ALK (-). Physicians should be alert to these new entities linked to silicone breast implants.

[Hepatitis E virus-associated aplastic anemia. Report of a case]

Hepatitis-associated aplastic anemia (HAAA) is a well-recognized clinical syndrome in which marrow failure follows the development of hepatitis; it can be observed in up to 5% in the aplastic anemia in West Europe and North American countries and 10% in the East Asia. Although hepatotropic and other viruses were suspected of causing HAAA, this hypothesis was rarely confirmed. Currently, the infection with hepatitis E virus represents the first cause of acute hepatitis in the world. Its genotype 3, the most frequent in Argentina and other Latin American countries, was associated with extrahepatic complications (renal, pancreatic, neurologic and hematologic). To our knowledge, only one case of hepatitis E virus-associated aplastic anemia has been previously reported, in Pakistan; the case presented here would be the first in Argentina. The patient was treated with thymoglobulin, cyclosporine, corticosteroids, filgastrim and transfusional support. She developed fungemia due to Candida tropicalis that remitted with equinocandins and therefore fever, pulmonary infiltrates and a solitary nodular cerebral image with serum galactomannan (DO index > 1.0 ng/ml) that resolved with voriconazol. She was discharged three months after her admission without transfusion requirements and normal hepatic values.With this in mind, it would be advisable to investigate hepatitis E (HEV) as a cause of HAAA in Argentina.

[Chylopericardium and bilateral chylothorax in a breast cancer patient]

Non traumatic chylopericar dium is mostly secondary to infection, congenital or neoplastic disease that invade mediastinal lymph nodes and modify the normal lymphatic flow. It is associated to chylothorax in approximately 3% of cases. We report the case of a 52 years old woman with diagnosis of advanced breast cancer. She was admitted with bilateral pleural effusion and echocardiographic signs of cardiac tamponade. A CT scan disclosed multiple mediastinal lymphadenopathy. The level of tryglicerides in pleural effusion was 372 mg/dl. A percutaneous pericardiocentesis was performed, obtaining chyle, with 984 mg/dl of tryglicerides and cholesterol 90 mg/dl levels. Treatment strategy was modified. We reviewed pathophysiology, diagnostic criteria and treatment of this rare entity.

[The outstanding achievements of Adolf Kussmaul]

BACKGROUND

Adolf Kussmaul was born in Graben, close to Karlsruhe, Germany, on February 22,1822. He graduated at Heidelberg University in 1845 and he received his medical degree in 1855. He made original descriptions, such as the ophthalmoscope, the gastroscope or endoscope, and Kussmaul signs, besides the respiration named after him. He was the first to perform a thoracocenteses, peritoneal and gastric lavages. He rediscovered progressive bulbar paralysis (previously described by Guillaume Duchenne in 1861), polyarteritis nodosa (which was described by Karl von Rokitansky en 1852), dyslexia, (described by Thomas Willis in 1672) and pulsus paradoxus named after him, but that was reported by Richard Lower in 1669. During his 80 years of life, he wrote about different issues and topics (cardiology, rheumatology, endocrinology, gastroenterology, psychiatry, and neurology). Kussmaul was a student and professional without limits in his observation capacity. He preached with his own example in pursuit of science: observation, hypothesis, experimentation and analysis.

[Vena cava filters in cancer patients]

Cancer patients with venous thromboembolism (VTE) have more complications related to the anticoagulation treatment than the general population. Vena cava filters are a useful tool in cancer patients, but their use in advanced disease is controversial. In this paper, we reviewed the indications, complications and frequency of retrieval of vena cava filters in cancer patients with VTE. Twenty seven patients with vena cava filter placements were analyzed. Twenty five had solid tumors and two non Hodgkin lymphomas. Twenty five were under active treatment (surgery and/or chemotherapy). Nineteen were classified as stage IV of disease. Indications for filter placement were perioperative prophylaxis in 14 cases (51.9%), hemorrhage (n = 5), thrombocytopenia (n = 4), central nervous system metastases (n = 2), stroke (n = 1) and previous neurosurgery (n = 1). Eight (29.6%) filters were retrieved. The median time to retrieval was 21 days (range: 6-75). There was no statistically significant difference in the frequency of retrieval between perioperative prophylaxis placement (6/14) and other contraindications for anticoagulation treatment (2/13; p = 0.2087). There were no adverse events related to the placement or retrieval procedures.

Autoimmune cholangitis associated to IgG4 related sclerosing disease

The IgG4-related sclerosing disease is characterized by the presence of plasmatic IgG4 positive cells and T-lymphocytes infiltration in different organs. We herein report a case of cholestasis due to autoimmune cholangitis associated to IgG4 disease. A 40-year-old woman with a history of pruritus, anosmia, Sjögren's syndrome and diabetes, was referred for a pancreatic tumor. Alkaline phosphatase was 24-fold upper limit of normal (ULN), gamma-glutamyl transpeptidase 21-fold ULN, aspartate aminotransferase 3-fold ULN, alanine aminotransferase 2-fold ULN, cholesterol 408 mg/dL, bilirubin normal, gamma-globulin 3.92 g/dL, IgG4 4.6 g/L, antinuclear antibody positive (1/320), and antimitochondrial antibodies negative. Ultrasound scan (US) showed a mass in the pancreatic head and thickening of the gallbladder and the bile duct walls. Dilation and strictures of the main pancreatic duct and intrahepatic bile ducts were detected by MR cholangiopancreatography. Liver biopsy showed chronic inflammatory lesions, ductal damage (autoimmune cholangitis) (METAVIRA2, F2) and IgG4 bearing plasmatic cells. A cervical lymph node showed IgG4 bearing plasmatic cells. After 2 weeks of treatment with meprednisone, ursodeoxycholic acid and insulin, pruritus and anosmia disappeared. After eleven months of treatment imaging studies showed disappearance of the pancreatic tumor, atrophy of the body and the pancreatic tail and normal biochemical parameters, except for alkaline phosphatase 2-fold ULN. The final diagnosis of our patient was autoimmune hepatitis with cholangitis associated to IgG4 systemic diseases.

[Transverse myelitis associated with anti-influenza A (H1N1) vaccination]

Transverse myelitis is an inflammatory disorder characterized by spinal cord dysfunction. Infectious, autoimmune, postinfectious and postvaccination diseases are the most common recognized causes of transverse myelitis, but near 50% of the cases are finally assumed as idiopathic. Rubeolla, mumps, rabies and influenza vaccines were associated with many neurologic complications, such as Guillain Barré Syndrome, acute disseminated encephalomyelitis (ADEM) and transverse myelitis. As a prevention measure after the 2009 pandemia, in February 2010 a National Campaigne of Vaccination against the Influenza A (H1N1) was started in our country. We report a case of a woman who received a monovalent Influenza A (H1N1) vaccine and four days after, began with sensory symptoms that progressed to a clear defined sensory level. She reached the clinical criteria of transverse myelitis, according to the Transverse Myelitis Consortium Working Group. One month later, the patient remained clinically stable and the MRI showed an improvement of the image without corticosteroids treatment. We discuss diagnostic, prognostic and therapeutic aspects of this clinical entity.

[Pericardial disease: from antiquity to the ultrasound]

Even if it is accepted that the first (accidental) pericardial resection was performed by Galen while trepanning the sternum of a patient with mediastinitis, it is surprising that the large historical gap in the description of pericardial diseases was closed until the studies from Richard Lower (1613-1691), demonstrated the role of the pericardium in human disease. Modern diagnostic tools currently allow to diagnose rapidly and precisely pericardial diseases. Through this article, we pretend to remember those physicians to whom we owe such advances in medicine.

Persistence with teriparatide in postmenopausal osteoporosis; impact of a patient education and follow-up program: the French experience

SUMMARY

This study evaluated the 18-month persistence with teriparatide in 5413 postmenopausal osteoporotic women who were enrolled in an education and follow-up program. Analysis showed that the persistence rate was 81.5% for women who follow the program, higher than for existing oral antiresorptive treatments.

INTRODUCTION

An education and follow-up program was developed after launch of teriparatide in France in September 2004, to help women to follow the treatment. The objective of this study was to evaluate the persistence with teriparatide in postmenopausal osteoporotic women following this program.

METHODS

Data about persistence are available for the period September 2004 to June 2007. Persistence is defined as the percentage of patients still on treatment at the end of the 18-month course, and it has been compared to the data provided by the French universal health insurance system.

RESULTS

Since the launch of teriparatide in France in September 2004, 5413 postmenopausal women (mean age 72.3 +/- 14.5 years) with osteoporosis and vertebral fractures (mean 3.9 +/- 2) have participated in the program. The persistence rate at 15 months was 81.5%, and our analysis suggested that a majority of patients completed the 18-month treatment course. The main reason for discontinuation was adverse events (46.7%). Data of the French Universal Health Insurance suggest that the persistence may be close to 0% for women who are not in the program.

CONCLUSIONS

Postmenopausal osteoporotic women treated by teriparatide and enrolled in an education and follow-up program have a high persistence rate.

[Pulmonary infiltrates in cancer patients]

Pulmonary infiltrates remain as a diagnostic and therapeutic challenge in cancer patients. In order to evaluate the etiology, diagnostic methods used, Intensive Care Unit admission and in-hospital mortality, we conducted an observational, prospective study which included all patients with cancer and recent pulmonary infiltrates admitted to the Instituto Alexander Fleming between August 2003 and March 2006. Diagnostic methods were categorized in sequential steps of complexity: 1st step: radiological pattern of the pulmonary infiltrates, blood and sputum cultures, serological tests and empirical treatment response; 2nd step: bronchoalveolar lavage (BAL), non bronchoscopic tracheal aspirate and mini-BAL; 3rd step: pulmonary or extrapulmonary biopsies. Pulmonary infiltrate etiology was classified as: infection, treatment complication, disease progression, cardiovascular or mixed. Diagnosis was classified as proved or probable. A total of 106 samples from 103 patients were included. The etiologies were infection in 61 cases, disease progression in 4, treatment complication in 6, cardiovascular in 6 and mixed in 7. Proved diagnosis was obtained in 33 cases and probable diagnosis in 51 while 22 cases could not be diagnosed. Nine of the 10 diagnoses of mycoses were in oncohematologic cases. Seventy cases did not go further than procedures included in the 1st step. Thirty two cases stopped after diagnostic procedures of the 2nd step and 4 required biopsies. Forty four cases required Intensive Care Unit admission. In-hospital mortality was 30.2%. In our study, infection was the most frequent etiology. Mycoses were more frequent in oncohematologic cases. A proved or probable diagnosis was obtained in 84 (79.2%) cases. In 53.7% of the cases only non-invasive diagnostic methods were required.

[Bivalvular non bacterial thrombotic endocarditis associated with cancer and transesophageal echocardiography]

Non bacterial thrombotic endocarditis is the most frequent cause of ischemic stroke in cancer patients. Up to 9% of autopsies of cancer patients show non infectious valvular masses. However, bivalvular involvement is not frequently occurring in 9% of non bacterial thrombotic endocarditis. We report a patient with ovarian cancer who presented aphasia. The MRI was compatible with cerebral ischemia. The transthoracic echocardiogram was normal and a transesophageal echocardiogram showed vegetations in aortic and mitral valves. We emphasize the importance of suspecting non bacterial thrombotic endocarditis in patients with cancer and systemic embolism and the low frequency of bivalvular involvement.

Non-scheduled consultation in oncologic patients. How many of them are true emergencies? An observational prospective study

Oncologic emergencies have been extensively described and clearly defined. In oncology daily practice, cancer patients seek non-scheduled medical care in situations they perceive as a medical emergency, but which may not be a true emergency. The aim of the study was to identify the main symptoms leading to a non-scheduled consultation (NSC) and their relationship to the type of cancer, and to evaluate whether the diagnosis at discharge of patients admitted as result of a NSC correlates with a true oncologic emergency. This was a prospective observational study. Between July 2002 and April 2003, 365 NSCs were recorded. The most frequent baseline diseases were breast cancer (70), lung cancer (67), gastrointestinal cancer (52), lymphoma (42) and ovarian cancer (22). The most common symptoms for consultation were: fever (84), pain (81), cutaneous manifestations (26), dyspnea (23), bleeding (16) and abdominal distention (16). Overall, 114 of 365 NSCs (31%) resulted in admission. The most frequent symptoms resulting in admission were fever (42), pain (16), dyspnea (11), vomiting (9), neurologic manifestations (7), abdominal distention (6) and anuria (6). At discharge, only 30 patients (26%) admitted after a NSC were diagnosed with a defined oncologic emergency: febrile neutropenia (13), intestinal occlusion (12), obstructive uropathy (4) and abdominal perforation (1). True emergencies were not the most frequent causes of NSC at our institution.

[Carcinomatous encephalitis]

We report a case of carcinomatous encephalitis in a patient with lung adenocarcinoma and confusional syndrome. This is a rare form of brain metastases. We discuss its clinical picture, the importance of suspecting it after a normal computed tomography scan and the miliary typical images at magnetic resonance.