Avyakta Kallam

Current and emerging treatment options for a patient with a second relapse of Hodgkin’s lymphoma

ABSTRACT Introduction: Hodgkin’s lymphoma (HL) is largely a curable disease with excellent prognosis. The standard of care in patients with relapsed disease has been to try salvage chemotherapy followed by an autologous stem cell transplantation (ASCT). Managing the patients who relapse after ASCT, is challenging. With the approval of targeted therapies such as PD-1 inhibitors, brentuximab vedotin, the outcomes have improved greatly. Areas covered: This review summarizes the current data available on the newer therapies as well as the present strategies used to treat patients with relapsed HL after an autologous stem cell transplantation. Expert commentary: The approval of brentuximab vedotin and PD-L1 inhibitors has ushered in a new era of targeted therapy in HL. There are currently several targeted therapies under investigation, particularly in the setting of relapsed disease. The current challenges faced are how best to integrate these newer therapies into the existing treatment regimens, finding a right combination with minimal toxicities, role of allogenic transplant in the era of targeted therapy.

Upper Limb Phlegmasia Cerulea Dolens Secondary to Heparin-induced Thrombocytopenia Leading to Gangrene

We present a case of a dialysis-dependent end-stage renal disease patient who originally presented with sepsis and later developed heparin-induced thrombocytopenia-related upper extremity deep venous thrombosis that rapidly progressed to phlegmasia. Argatroban, a direct thrombin inhibitor, was initiated without delay. Argatroban restored the venous patency completely but did not reverse his two gangrenous fingers. The patient finally underwent digital amputation. The management of this uncommon, but life-threatening, situation of upper limb phlegmasia cerulea dolens secondary to heparin-induced thrombocytopenia leading to gangrene is discussed in this case report.

Gray Zone Coping with Knife: Post-operative Management of Nodular Lymphocyte Predominant Hodgkin Lymphoma

A 47-year-old woman presented to her primary care physician with right arm pain and paresthesias, prompting cervical magnetic resonance imaging. Imaging revealed C6-7 spinal stenosis and an incidental T2 hyperintense left thyroid nodule measuring 1.9 cm (Fig. 1). A neck ultrasound scan revealed a 3.2 2.8 cm spongiform left thyroid nodule and a 0.7 0.6mm inferior right isthmus nodule. Fine needle aspiration of the left thyroid nodule demonstrated abundant mixed lymphoid cells. The patient underwent left hemithyroidectomy with pathology showing a 2.2 2.0-cm nodular lymphocyte predominant Hodgkin lymphoma (Fig. 2). The posterior and inferior surgical margins were negative but less than 0.1 mm from the inked margin. Postoperative positron emission tomographyecomputed tomography demonstrated no evidence of residual locoregional or distant disease.

Paraneoplastic Manifestations of Lymphoproliferative Neoplasms

Paraneoplastic syndromes, although rare, have been associated with lymphoproliferative disorders. Hodgkin’s lymphoma (HL) is the most common lymphoid neoplasm known to cause paraneoplastic syndromes. These syndromes can often be the earliest manifestation of the underlying malignancy, and treating the underlying lymphoma can cure the paraneoplastic disease. Paraneoplastic diseases reported in lymphoid malignancies can be broadly classified into hematological, neurological, and dermatological syndromes based on the organ systems that are predominantly involved. In addition, renal and hepatobiliary involvement has also been reported. The pathogenesis of the hematological paraneoplastic conditions primarily involves the production of autoantibodies by the neoplastic lymphocytes, which then subsequently leads to cytopenias. Cytoses are a result of cytokine produced by the neoplasms. The administration of corticosteroids along with chemotherapy for the underlying malignancy is the treatment of choice. Neurological paraneoplastic phenomena have been reported in both HL and non-Hodgkin’s lymphoma (NHL). They are thought to be secondary to an immune-related process that is triggered by the underlying process. Both the central and the peripheral nervous systems can be affected. Often, treatment of the underlying malignancy with chemotherapy can result in reversal of the paraneoplastic syndrome. In peripheral neuropathies, muscle relaxants and analgesics are often used for symptomatic relief. Dermatological manifestations, pemphigus vulgaris in particular, often precedes the malignancy. Renal and hepatobiliary manifestations, although rare, are also associated with lymphomas.

Kikuchi's Disease Masquerading As Refractory Lymphoma

Positron emission tomographic (PET) scanning with a near-simultaneous computedtomography(CT)scan(ie, integrated PET-CT scan) is the preferred imaging modality for staging lymphomas. PET scanning detects Hodgkin lymphoma as well as the aggressive and most indolent non-Hodgkin lymphomas. PET-CT has become the standardof care for assessment of remission in patients with [F]fluorodeoxyglucose (FDG)-avid lymphomas, including Hodgkin lymphoma. The use of PET-CT scans for restaging is not without pitfalls. Although the sensitivity of a PET scan is nearly 100%, the positive predictive value is lower. We report the case of a woman with a history of Hodgkin lymphoma who was noted to have new lymphadenopathy in a restaging scan, implying progression of the disease. However, on further workup, it was determined that this was not the case.

Physician-Ordered Aerosol Therapy Versus Respiratory Therapist-Driven Aerosol Protocol: Effect on Resource UtilizationThe authors respond to: Physician-Ordered Aerosol Therapy Versus Respiratory Therapist-Driven Aerosol Protocol: Effect on Resource Utilization

To the Editor: The article by Kallam and colleagues[1][1] about the potential financial advantages of protocol-driven bronchodilator therapy provides an important perspective. However, there are no data about the validation of the scoring tool or the evidence supporting the correlation of the