Sidra Khalid

Dosage Adjustments for Chemotherapy and Targeted Therapies in Colorectal and Pancreatic Cancer Patients with Hepatic Impairment

There are many novel chemotherapeutic options and targeted therapies available for the treatment of colorectal and pancreatic cancer. Patients with these cancers often have hepatic impairment either from the metastasis to the liver or from the chemotherapy or targeted therapies used to treat the disease. It is important to describe the effects of these agents in patients with hepatic impairment. This article will review the dosage recommendations for the chemotherapy regimens and targeted therapies in colorectal and pancreatic cancer patients in the setting of hepatic impairment.

Risk Factors and Management of Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy is characterized by transient left ventricular apical ballooning, which results in temporary left ventricular dysfunction. We present a case of a 62-year-old female who presented with chest pain and shortness of breath. Her electrocardiogram was suggestive of myocardial ischemia and her troponin levels were elevated. Cardiac catheterization showed mild coronary artery disease and left ventriculography revealed severe apical hypokinesia. A diagnosis of Takotsubo cardiomyopathy was made. Her hospital stay was complicated by cardiogenic shock. One of the risk factors was cannabis use. Hence, our case highlights the management of Takotsubo cardiomyopathy and its complications, along with focus on cannabis use and its association with Takotsubo cardiomyopathy.

Primary Splenic Diffuse Large B-Cell Lymphoma: A Rare Case of Massive Splenomegaly and Thrombocytopenia

Primary splenic diffuse large B-cell lymphoma (DLBCL) is a rare type of non-Hodgkins lymphoma. It often presents with abdominal pain or splenomegaly. We present a case of a 68-year-old male who presented to the emergency department with left sided abdominal pain. Workup revealed massive splenomegaly and thrombocytopenia. A splenic biopsy confirmed the diagnosis of primary splenic DLBCL. The patient was treated with chemotherapy. This case highlights the importance of considering primary splenic DLBCL with splenomegaly and treating it with chemotherapy and/or splenectomy.

Management of Primary Mediastinal B-Cell Lymphoma in Pregnancy

Primary mediastinal B-cell lymphoma (PMBCL) is a subtype of non-Hodgkin’s lymphoma, which occurs rarely in pregnancy. We present a case of a pregnant 22-year-old female who presented with syncope and dyspnea. Computed tomography (CT) chest showed an anterior mediastinal mass, and its biopsy showed PMBCL. Since she was in her second trimester, we decided to treat her with rituximab-cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP). Our case emphasizes the safety of chemotherapy in the second and third trimesters, with good maternal and fetal outcomes.

A Case of Postpartum Ovarian Vein Thrombosis

Ovarian vein thrombosis (OVT) is an rare condition, which can present in the postpartum period. We present a case of a 35-year-old female who presented with right lower quadrant pain and fever. Her computed tomography (CT) abdomen revealed a dilated right ovarian vein with soft tissue attenuation material in its lumen that extended into the inferior vena cava, along with fat stranding of the surrounding soft tissues signifying thrombophlebitis. She was treated with enoxaparin and piperacillin-tazobactam, which lead to a resolution of the thrombus. Our case highlights the importance of prompt diagnosis and treatment of OVT in order to prevent morbidity and mortality.

May-Thurner Syndrome: A Rare Cause of Deep Venous Thrombosis

May-Thurner syndrome (MTS) is a medical condition where the left iliac vein is compressed by the right iliac artery, which in turn predisposes patients to deep venous thrombosis (DVT). We present a case of a 67-year-old female who had pain and swelling of the left leg. Ultrasound of the deep veins of the leg revealed DVT of the distal external iliac vein. She was treated with catheter-directed thrombolysis and stent placement. Finally, she was discharged on long-term anticoagulation with warfarin. The purpose of presenting this case is to highlight the clinical presentation, diagnosis, and treatment of MTS.

Fibromuscular Dysplasia Presenting as a Renal Infarct

Fibromuscular dysplasia (FMD) is a condition caused by an abnormal development or growth of cells in the arterial walls in the body. We present a case of a 49-year-old male who came in with a sudden onset of severe left-sided abdominal pain. Computed tomography (CT) scan of the abdomen was suggestive of a left renal infarct. He underwent renal angiography that showed FMD and a clot located in the anterior branch of the left renal artery. The patient was then treated with apixaban for the clot and amlodipine for the associated hypertension. Our case will highlight the importance of recognizing renal infarction as an initial presentation of FMD.

Desensitization of Brentuximab Vedotin in a Patient with Hodgkin Lymphoma

Brentuximab vedotin is a monoclonal antibody that targets the CD30 antigen. It is indicated for the treatment of Hodgkin lymphoma. Hypersensitivity reactions have occurred during infusions of brentuximab vedotin, ranging from mild to severe. We report a case of a 46-year-old male with stage IV nodular sclerosis Hodgkin lymphoma who developed a hypersensitivity reaction to brentuximab vedotin. He experienced a generalized rash, facial swelling, and mild airway obstruction. In order to continue treatment with brentuximab vedotin, we implemented a desensitization protocol. He was premedicated and a 12-step process was performed in which brentuximab vedotin was titrated over three hours. The protocol was successful, allowing the patient to receive subsequent infusions without hypersensitivity reactions.

Management of Atrial Fibrillation in Patients on Ibrutinib: A Cleveland Clinic Experience

Background Ibrutinib is a Bruton’s tyrosine kinase inhibitor, which is United States Food and Drug Administration (FDA)-approved for chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenström’s macroglobulinemia. Ibrutinib is associated with atrial fibrillation and bleeding events. Our aim is to determine the management of prior atrial fibrillation when starting ibrutinib, as well as ibrutinib-induced atrial fibrillation. Our focus is on which rate and rhythm control strategies to use and decisions regarding the use of antiplatelet and anticoagulation agents. Materials and Methods We conducted a retrospective descriptive study of case records over a three-year period from February 2014 to February 2017. We reviewed 597 patient charts from the Cleveland Clinic database. Ibrutinib was started in 43 patients. Of those, 10 had atrial fibrillation prior to starting ibrutinib and four developed atrial fibrillation while on ibrutinib. Data was collected for demographic details, co-morbid conditions, CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, prior stroke, transient ischemic attack or thromboembolism, vascular disease, age, and sex category) score, HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile INR, elderly, and drugs or alcohol) score, and drugs used for antiplatelet effects, for anticoagulation, and for rate and rhythm control. Outcomes for embolic and bleeding events were assessed. Results Of the 43 patients, 14 (32.5%) had or developed atrial fibrillation; 10 (23.26%) had prior atrial fibrillation, and four (9.30%) developed atrial fibrillation after starting ibrutinib. The majority were males (71.42%) and Caucasian (71.42%). The disease breakdown was chronic lymphocytic leukemia (42.86%), mantle cell lymphoma (50%), and Waldenström’s macroglobulinemia (7.14%). The mean starting dose of ibrutinib in patients with prior atrial fibrillation was 569 mg and for patients who developed atrial fibrillation was 420 mg. In the 10 patients who had atrial fibrillation prior to ibrutinib, all 10 were on beta blockers, one was on diltiazem, three were on amiodarone, one was on flecainide, one was on digoxin, and one was on Tikosyn® (Pfizer, Inc., New York, NY). The ibrutinib dose was decreased/discontinued in two patients. In patients who developed atrial fibrillation after starting ibrutinib, three were on beta blockers, two on amiodarone, and one on Tikosyn. Ibrutinib was discontinued in one patient. In patients who had prior atrial fibrillation, three were on warfarin, one on enoxaparin, and two on apixaban. In three patients, aspirin and enoxaparin were discontinued. In patients who developed atrial fibrillation after starting ibrutinib, enoxaparin was given to two and apixaban to one. None of the patients had a stroke, transient ischemic attack (TIA), or bleeding events. Conclusions From our study, we concluded that ibrutinib can be safely given in the presence of atrial fibrillation, and when atrial fibrillation was induced, we further concluded that beta blockers were the preferred agents for rate control. Ibrutinib has many drug interactions with other rate and rhythm control agents; hence, their use was lower. When atrial fibrillation was uncontrolled, ibrutinib was temporarily held and then cautiously restarted. The decision to start or adjust anticoagulation depended on the bleeding and stroke risks as assessed by their physicians.

Management of a Rare Variant of Hypertrophic Cardiomyopathy

Apical hypertrophic cardiomyopathy (HCM) is a rare variant of HCM. We present the case of a 26-years-old female who was diagnosed with apical HCM. Her electrocardiogram showed the characteristic T-wave inversions in V2-V5 and her echocardiogram portrayed apical left ventricular hypertrophy. The diagnosis was confirmed with a cardiac magnetic resonance imaging (MRI) scan. She was treated with beta blockers. Our case emphasizes that apical HCM is a relatively benign disease. However, due to the emerging evidence of sudden cardiac deaths in these patients, the risk for sudden death needs to be evaluated.