Yanina Pasikhova

Nocardiosis following hematopoietic stem cell transplantation

Nocardia species are ubiquitous environmental organisms that can cause a diverse spectrum of disease. Clinical manifestations range from localized skin and soft tissue infections to life‐threatening pulmonary, central nervous system, and/or disseminated infections. Patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) are at risk for nocardiosis, and further data in regard to characteristics of disease in this population are warranted.

Successful management of Mycobacterium haemophilum lower extremity cutaneous infection in a matched‐unrelated donor stem cell transplant recipient

Nontuberculous mycobacterial infections can often occur in individuals with adequate immune function. Such infections typically have cutaneous involvement and are caused by rapidly growing mycobacterium. Other nontuberculous mycobacteria species, like Mycobacterium haemophilum, almost always present as opportunistic infections occurring in severely immunocompromised hosts. Here, we present a complicated and protracted course of diagnosing M. haemophilum lower extremity cutaneous infection in a matched‐unrelated donor stem cell transplant recipient.

Early Antimicrobial De-escalation and Stewardship in Adult Hematopoietic Stem Cell Transplantation Recipients: Retrospective Review

Abstract Background Antimicrobial stewardship in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients remains underutilized in North America. European guidelines advise de-escalation of broad-spectrum therapy after 72 hours in select patients with neutropenic fever of unknown origin. This is not commonplace in the United States, as current guidelines recommend broad-spectrum therapy until neutrophil engraftment. If de-escalating after at least 5 days of broad-spectrum therapy and defervescence in neutropenic allo-HSCT recipients does not predispose them to recurrent fever or infection, the practice could afford several benefits. Methods The primary end point was rate of recurrent fever. Secondary outcomes included Clostridium difficile–associated infections, length of stay, intensive care unit (ICU) admission incidence, in-hospital mortality rate, need for re-escalation of therapy, rate of positive blood cultures for patients who had recurrent fevers, overall antimicrobial utilization from neutropenic fever onset, and pharmacoeconomic impact. Results A total of 120 patients were assessed in 2 groups as cohort 1 (n = 46), which received early de-escalation, and cohort 2 (n = 74), which did not. The primary end point met criteria for noninferiority, as 7 patients (15%) in cohort 1 had recurrent fever within the specified time frame compared with 14 (19%) in cohort 2 (90% CI, –0.0878 to 0.1629, P = .026). Patients in cohort 1 received significantly less gram-positive broad-spectrum antimicrobials, with trends toward lower use of broad-spectrum gram-negative agents and lower associated costs and no differences in length of stay, ICU admission incidence, need for re-escalation of therapy, rate of culture-positive bacteremia after de-escalation or discontinuation of broad-spectrum therapy, or in-hospital mortality rate. Conclusions De-escalating after at least 5 days of broad-spectrum therapy and defervescence did not appear to affect the rate of recurrent fever. This allowed for significant reductions in gram-positive broad-spectrum antimicrobial utilization, with trends toward lower use of broad-spectrum gram-negative agents and associated costs and no difference in clinical outcomes compared with those continuing such therapy until neutrophil engraftment.

Fever in Patients with Cancer

BACKGROUND The definition of fever is flexible and depends on the clinical context. Fever is frequently observed in patients with cancer. METHODS Infectious and noninfectious causes of fever in patients with various oncological and hematological malignancies and the usefulness of biomarkers are discussed. RESULTS To treat patients in a timely manner and to minimize morbidity and mortality, it is paramount that health care professionals determine the cause of fever. The usefulness of biomarkers in febrile patients with cancer continues to be controversial. CONCLUSIONS Fever is frequently seen in patients with cancer and can be associated with a variety of infectious and noninfectious causes. The utility of acute-phase reactants, such as erythrocyte sedimentation rate, C-reactive protein, and procalcitonin, along with a nonsteroidal anti-inflammatory drug challenge should be further evaluated as adjunct tools for the workup of fever in patients with cancer.

Cumulative dermatologic toxicity with ipilimumab and vemurafenib responsive to corticosteroids

Dermatologic toxicity is a known reaction of ipilimumab and vemurafenib. Because of the lack of effective treatments and aggressive nature of melanoma, treatments are often discontinued and new treatments are initiated in rapid succession. We report what we believe to be the first case of cumulative dermatologic toxicity secondary to rapid-sequential treatment with ipilimumab and vemurafenib for metastatic melanoma that responded to high-dose steroids. This case highlights the combined toxicity of these two drugs that can occur as a result of overlapping toxicity. It also illustrates the need for a substantial wash out period between rapid cycling of these two drugs secondary to ipilimumabs long half-life.

New-onset toxicity with programmed death-1 inhibitor rechallenge.

Immunotherapy has become a mainstay in the treatment of metastatic melanoma. Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) inhibitors and programmed death-1 (PD-1) inhibitors, which have been added more recently, represent two of the main classes of immunomodulating agents. PD-1 inhibitors are well tolerated and are known to have a decreased rate of occurrence of adverse effects compared with CTLA-4 inhibitors. However, the risk remains for serious immune-mediated adverse reactions. Given their long half and extended efficacy, treatment with a CTLA-4 inhibitor before use of a PD-1 inhibitor may increase the risk of adverse effects. In addition, caution should be exercised when rechallenging grade 3 or 4 adverse effects with the same agent or a different agent of the same class. The re-emergence of a previous toxicity may occur or, as found in this case, a new severe effect may arise. This article will present a case of fatal immune-related hepatoxicity in a patient treated with a CTLA-4 inhibitor, followed by treatment with a PD-1 inhibitor. The mechanisms of action and safety profiles for both classes of drugs will also be reviewed.

Mycoplasma hominis–Associated Cystitis, Pyelonephritis, and Bacteremia in an Allogeneic Hematopoietic Stem Cell Transplant Patient

Mycoplasma hominis, a commensal organism of the human genital tract of sexually active males and females, can be an atypical cause of both genitourinary tract and nongenital infections. We describe a case of M. hominis infection in a patient receiving oral immunosuppression after allogeneic hematopoietic stem cell transplantation for treatment of acute myeloid leukemia. The patient presented with complaints of chronic cystitis, suprapubic pain, bladder spasms, and an abnormal urinalysis. Mycoplasma hominis was cultured from both the urine and blood and was determined to be the source of infection in this patient. This organism is intrinsically resistant to several classes of antibiotics; however, it is largely susceptible to tetracyclines and clindamycin. Doxycycline is often the agent of choice for treatment ofM. hominis infections, because of its favorable pharmacokinetic profile. The patient was treated with a 3-week course of doxycycline and reported resolution of all urinary symptoms.

Pulmonary Infections With Mycobacterium avium-intracellulare in Women With Confirmed or Suspected Malignancy: A Retrospective Observational Study, 1987–2011

BackgroundIn the last 2 decades, there has been an increased interest in infections caused by nontuberculous mycobacteria (NTM). Mycobacterium avium complex is the most common PNTM in the United States. Pulmonary disease caused by MAI is often chronic and occurs particularly in the elderly, in women frequently without underlying lung disease. Although NTM infections are reported in patients with malignancy, few studies investigated the epidemiological, clinical, and radiological characteristics of pulmonary MAI infection in women with cancer. Materials and MethodsWe retrospectively reviewed medical and microbiologic records and radiographic findings of all female patients seen at the Moffitt Cancer Center in Tampa, Florida, with positive lung specimen cultures for MAI from January 1987 to January 2011. Microbiologic records included the cultures of expectorated sputum samples, bronchial wash or lavage, and lung biopsies. Radiographic findings obtained by high-resolution computed tomography permitted a classification of the lung MAI disease in 3 forms: cavitary, nodular bronchiectatic, and nodular form. ResultsA total of 46 patients met the inclusion criteria during a 24-year period. The median age at the time of diagnoses was 68 years. There were some patients who had an underlying cancer, an underlying chronic lung disease, and a comorbid condition. Cough was the most common pulmonary symptom in most of our patients. The most common radiologic finding was consistent with a single nodule. A few of the female patients were definable as Lady Windermere syndrome. Symptomatic improvement was seen in most of the patients with either a monotherapy or a combination therapy. ConclusionsPhysicians need to be aware of the possibility of coexisting pulmonary MAI in elderly women with cancer, principally breast and lung cancer, or chronic lung disease, with a chronic cough and a new nodule on the lung computed tomography scan. Early suspicion can lead to appropriate diagnosis, prompt therapy, and reduction of mortality.

Cytomegalovirus Encephalitis in an Allogeneic Hematopoietic Cell Transplant Recipient: A Case Report and Review of Literature

AbstractCytomegalovirus (CMV) commonly reactivates in seropositive recipients after allogeneic hematopoietic cell transplant but rarely causes infection. Since the implementation of preemptive approaches, infection by CMV has become a rare occurrence. We describe the successful treatment of a case of late ganciclovir-resistant CMV encephalitis occurring 2 ½ years after an HLA-mismatched allogeneic hematopoietic stem cell transplant.