Moffitt week in review 2/18-21

On Tuesday, we discussed a case of a patient with a history of multiple myeloma who presented with worsening HFpEF and was found to have suspected cardiac amyloidosis.

We discussed a differential dx for low voltage ECG, and first of all reminded ourselves how to define “low voltage”:

  • Amplitudes of all QRS complexes in limb leads are < 5 mm  — OR –
  • Amplitudes of all QRS complexes in the precordial leads are < 10 mm

For the approach to a low voltage ECG, we broke this down into 2 buckets: (1) things that get between electrodes and the heart and (2) abnormalities of the myocardium itself:

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On Wednesday, Alex shared a case of a patient with recent prolonged hospitalization with multiple immune-related adverse events associated with immune checkpoint blockade, who was now presenting with pneumonia with parapneumonic effusion.

We discussed some of the organ-specific adverse events associated w checkpoint blockade, noting that the most commonly seen organs involved in these adverse events are:

  • Skin (dermatitis)
  • GI (enteritis/colitis/hepatitis)
  • Endocrine organs (thyroiditis, hypophysitis, primary adrenal insufficiency)

Have questions about immune-related adverse events? So do we, and so do a lot of people, apparently. This NEJM review from 2018 (https://www.nejm.org/doi/full/10.1056/NEJMra1703481) focuses on 10 questions that we often encounter when caring for this expanding patient population! Check out the summary table below:

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On Thursday, Anna presented the case of a patient who had a liver transplant more than 10 years ago with a complicated subsequent course. This patient had chronic rejection requiring multiple immunosuppressants (recently on all 4 of everolimus, sirolimus, mycophenolate and prednisone) and had multiple infectious complications including CMV retinitis, and cryptococcal meningitis. He was now presenting with weeks of fevers, malaise and generalized weakness.

We discussed a helpful approach to a decompensation in a patient with a history of a solid organ transplant:

  1. Infectious complications of immunosuppression
  2. Malignant complication of immunosuppression (transplant patients on chronic immunosuppression are at higher risk for multiple malignancies including lymphoproliferative disorders)
  3. Toxicity of immunosuppression (e.g. renal toxicity and neuro toxicity related to calcineurin inhibitors cyclosporine and tacrolimus)
  4. Rejection of the transplanted organ
  5. Progression of the underlying disease that led to the transplant in the first place

Our patient developed acute one-sided weakness in the hospital, and had an abnormal NCHCT w hypodensity in the thalamus and hyperdensity in the frontal lobe. Further w/u including MRI, LP, and eventually brain led to the diagnosis of a primary CNS post-transplant lymphoproliferative disorder (PTLD).

A couple of pertinent bits of info about PTLD:

  • The incidence in solid organ transplant recipients is ~ 1% at 10 years. This varies by type of transplant and by degree of immunosuppression

Who is at highest risk?

  • patients with marked immunosuppression
  • EBV positive patients

When does it occur?

  • 80% of these malignancies occur in first year after transplant (likely related to high degree of immunosuppression during that time)

How does it present? If there is no lymphadenopathy, can we rule it out?

  • Presentation is highly variable depending on areas involved – often associated with non-specific symptoms such as fever, weight loss and fatigue
  • More than half present with with extranodal masses – these can be in the CNS (as in our patient), in the transplanted organ or elsewhere

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On Friday at ambulatory report, Arturo presented a young woman with a history of type 1 diabetes and steatohepatitis who presented with diffuse bony pain and unexplained ecchymoses.

We discussed an approach to abnormal bleeding, including running through the categories of blood, vWF and vessel wall. Check out this schema courtesy of Rabih Geha.

Based on the work-up Arturo had already pursued in clinic, we were most suspicious for a vessel wall problem. We’ll leave you with another beautiful schema courtesy of Rabih!

Moffitt week in review 2/18-21