Saurabh Dahiya

Sleep disturbances in cancer patients: Underrecognized and undertreated

Sleep-related complaints are extremely common in patients with cancer but often are not recognized, and even if they are, they are seldom treated. Recognizing insomnia in cancer patients is imperative, as appropriate treatment can improve quality of life. In cancer patients, sleep disturbances are a treatable problem that profoundly affect all aspects of quality of life.

Bevacizumab in high-grade gliomas: past, present, and future

The survival of patients with high-grade gliomas (anaplastic gliomas and glioblastoma) remains poor despite current treatment modalities. However, an enhanced understanding of gliomagenesis is supporting the development of targeted molecular therapies with the potential for improving clinical outcomes. Glioblastoma (GBM) is characterized by extensive microvascular proliferation and the production of large amounts of VEGF. Bevacizumab is a humanized IgG1 monoclonal antibody that selectively binds with high affinity to human VEGF and neutralizes VEGF’s biologic activity. Preclinical data indicate that angiogenesis is essential for the proliferation and survival of GBM cells. A number of studies have evaluated the outcomes of both newly diagnosed and recurrent GBM patients with bevacizumab in a prospective manner. Here, we discuss the role of bevacizumab in the treatment of anaplastic gliomas and GBM in the recurrent and upfront setting.

Spontaneous bilateral adrenal hemorrhage.

A 46 year old male with medical history of hypertension, gastroesophageal reflux disease (GERD) presented to emergency room with abdominal pain for over a month. He described his abdominal pain as crampy in nature and was mostly located in left flank. Upon further questioning he attested to a history of nausea with occasional vomiting, dizziness upon standing, and weight loss of about over 10 lbs in past 1 month. He also mentioned visiting his primary care doctor and emergency room for the abdominal pain in last month. He was told it is related to GERD or possibly a kidney stone and was discharged home. His physical examination at presentation revealed tachycardia, minimal left flank tenderness and was otherwise normal. Initial laboratory data revealed evidence of hyponatremia, acute kidney injury, and a lactate of 3.7 mmol/l. Few hours later, a CT of abdomen without contrast was performed which showed diffuse enlargement of bilateral adrenal glands with adjacent inflammatory changes and was reported not to have the appearance of adrenal hemorrhage (Fig. 1). A random cortisol level was obtained and revealed a level 0.6 mcg/dl suggesting severe adrenal insufficiency. Soon after, patient was commenced on stress dose hydrocortisone. The first dose of hydrocortisone was given almost 10 h later to the presentation to the hospital. Within an hour of administration of steroids patient went into a cardiac arrest and was coded almost for 30 min before return of spontaneous circulation. An exhaustive infectious workup including multiple blood cultures, CT chest for identifying possible underlying infection precipitating adrenal crisis was negative. Workup for adrenomegaly leading to adrenal crisis included tuberculin test, adrenal cortex antibody, HIV, RPR, ANA, anticardiolipin antibody, anti-phosphatidylserine antibody, histoplasma antibody and was unrevealing. Patient remained on ventilatory and vasopressor support for next 3 days. In view of poor neurological recovery and per family wishes, care was withdrawn. An autopsy exam was obtained and revealed bilateral adrenal hemorrhage as the cause of adrenomegaly.

Paraneoplastic autoimmune hemolytic anemia in ovarian cancer: a marker of disease activity

Autoimmune hemolytic anemia (AIHA) is a rare paraneoplastic syndrome associated with ovarian malignancies. We report a case of a 77 year-old female with metastatic ovarian carcinoma who presented with worsening anemia from her baseline, and was found to have a warm autoimmune hemolytic anemia. We performed a literature review and analyzed all 10 cases (including our patient) that have been reported to date, and incorporated the clinical presentation, histology and stage of underlying malignancies, types, treatment, prognosis and mechanisms of AIHA in ovarian carcinoma.

Gangrene from finger pricking

A 54-year-old diabetic man with end-stage renal disease on hemodialysis, presented to the outpatient clinic with complaints of ulcer on his fourth finger of the right hand. Examination showed a small, well-defined area of skin necrosis involving the finger tip. He reported using that particular site for finger pricking for self-monitoring of blood glucose. In spite of conservative treatment measures, the area of skin necrosis progressed to gangrene of finger tip. The patient eventually underwent partial amputation of the right fourth finger (Fig. 1). Repeated finger pricking can induce severe disturbances of microcirculatory skin perfusion in patients with diabetes mellitus and underlying vascular disease. Regular inspection of the sites used to obtain capillary blood samples may prevent such deterioration. Newer methods of blood glucose monitoring, such as alternate-site testing or non-invasive glucose monitoring, should be evaluated further.

An unusual cause of delirium and debility: refractory hypercalcemia in a man with b-cell prolymphocytic leukemia

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Primary testicular lymphoma with cardiac involvement in an immunocompetent patient: case report and a concise review of literature

Primary testicular lymphoma (PTL) is a rare testicular tumor representing less than 9% of all testicular cancers. PTL usually tends to spread to or relapse at nodal structures or extra-nodal sites such as contralateral testes, central nervous system, skin, lung, pleura, waldeyers ring and soft tissues. We present a case of PTL with huge left atrial mass, an extremely unusual site of involvement. Early disease usually carries a good prognosis, whereas advanced stage carries an extremely poor prognosis. Herein, we report the complete remission to date in a patient with advanced stage PTL with huge left atrial mass, treated with systemic rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone and intrathecal methotrexate. A brief review of literature focusing on various aspects of management of primary testicular lymphoma and lymphomatous involvement of heart is also discussed.

Primary central nervous system posttransplantation lymphoproliferative disorder in an elderly liver transplant recipient.

Conflict of Interest: None. Author Contributions: Concept and design: WingKeung Cheung and Szu-Fen Huang. Acquisition of participants and data: Wing-Keung Cheung, Min-Po Ho. Analysis and interpretation of data: Wing-Keung Cheung, Min-Po Ho, Ming-Chow Wei, Pei-Wei Shueng, Szu-Fen Huang. Preparation of manuscript: Wing-Keung Cheung. Critical review and approval: All authors. Sponsor’s Role: None.

Relapse pattern and prognosis of primary CNS lymphoma

TO THE EDITOR: We compliment the work of Kim et al., on relapse patterns and prognosis of primary CNS lymphoma (PCNSL) [1]. Analyzing data on 65 patients with newly diagnosed PCNSL, authors conclude that regular systemic evaluation of extra-cranial site may not always be necessary. They also report that age less than 60 to have better overall survival (OS) and patients who received chemotherapy followed by autologous stem cell transplantation (Ctx-ASCT) to have better failure free survival (FFS). This study is one of the few studies to analyze PCNSL relapse patterns and the first study so far to analyze impact of Ctx-ASCT as compared to other treatment options in PCNSL.

Spontaneous coronary artery dissection - a mimic

Spontaneous coronary artery dissection (SCAD) is a rare but potentially life-threatening condition if it goes unrecognized. Symptoms can range from chest pain to sudden cardiac death. We present a case of 33 year-old female marathon runner who presented to emergency department (ED) complaining of sudden onset of non-positional, constant, pleuritic chest discomfort. She was eventually found to have spontaneous dissection of coronary artery. The mimicking nature of SCAD is presented in this article. We conclude that spontaneous coronary dissection, although still challenging due to its mimicking nature, should be considered in the differential diagnosis of chest pain and associated myocardial injury.