Hyperviscosity Syndrome Induced Bilateral Visual and Auditory Impairment in Therapy Resistant Waldenström Macroglobulinemia with MYD88 and CXCR4 Mutations

Hyperviscosity syndrome (HVS) is an emergent complication of Waldenström macroglobulinemia (WM) characterized by visual, neurologic, and rarely auditory impairment. We report a 69-year-old female with MYD88 and CXCR4-mutant WM who developed HVS resulting in bilateral blindness and deafness associated with neurologic manifestations including confusion, severe generalized weakness, and imbalance. Ophthalmologic evaluation revealed bilateral central retinal vein occlusion (CRVO), diffuse retinal hemorrhages, macular edema, and serous macular detachments (SMD). Magnetic resonance imaging of the brain showed bleeding in the inner ears. Management was challenging as her WM was resistant to systemic therapies including bendamustine + rituximab (BR) and rituximab + bortezomib + dexamethasone (RVD). Bruton's tyrosine kinase inhibitors could not be used initially due to ongoing lower gastrointestinal bleeding. She required five total sessions of plasma exchange and was finally initiated on zanubrutinib, achieving a partial response. She also received intravitreal bevacizumab with rapid resolution of the retinal hemorrhages but with little improvement of the SMD. She had partial restoration of her hearing in the right ear and only slight improvement in her bilateral visual deficits. The management of HVS in frail, elderly patients with therapy-resistant WM can be challenging. In these cases, plasma exchange is required until an effective systemic therapy can be safely instituted. Genomic profiling is important in the management of WM as it can predict treatment resistance and guide therapeutic decisions.

Immune Checkpoint Inhibitor-Induced Pure Red Cell Aplasia: A Review of 2 Cases in Metastatic Melanoma

BACKGROUND Immunotherapy is a novel treatment offering an alternative to traditional chemotherapeutic agents for different malignancies. Hematologic adverse reactions (HARs) related to immune checkpoint inhibitors (ICIs) are uncommon. Pure red cell aplasia (PRCA) is a rare hematologic complication of ICI therapy in metastatic melanoma with significant mortality risk despite treatment with steroids or immunosuppressive therapy. For unexplained acute anemia after exclusion of other causes, performing bone marrow biopsy is imperative to diagnose PRCA and rule out involvement of bone marrow by primary tumor. HARs can occur during ICI therapy or even after ICI therapy is stopped. ICI rechallenge, even after the development of HARs, is considered in some patients with good response to treatment of HARs from ICIs. Recurrence of HARs with the same or different type of reaction is seen in some patients. CASE REPORT Two cases of ICI-induced PRCA were confirmed on bone marrow biopsy after dual ICI treatment with nivolumab and ipilimumab in metastatic melanoma. In case 2, PRCA was successfully treated with steroids and later rechallenged with single-agent nivolumab, causing mild ICI-induced immune thrombocytopenia, which did not require treatment with steroids. CONCLUSIONS It is crucial to increase clinician awareness of the possibility of PRCA development not only during treatment with ICI but also after finishing treatment with ICI; there is high mortality associated with missing an opportunity to diagnose and treat PRCA on time with favorable results. ICI rechallenge can be considered in patients who showed response to immunotherapy, especially those with limited alternative therapeutic options.

The "starfield" pattern of cerebral fat embolism from bone marrow necrosis in sickle cell crisis

Sickle cell disease may manifest with cerebrovascular and systemic complications. Sickle crisis that results in avascular necrosis of long bones with resultant cerebral fat embolism syndrome is rare and has a characteristic "starfield" pattern on MRI. This "starfield" MRI pattern should raise suspicion for sickle cell crisis in patients without a known history of the disease, which can lead to earlier sickle cell red blood cell exchange transfusion and treatment. We present a case of a male who presented emergently with acute seizure, coma with a characteristic MRI pattern, which lead to the diagnosis of avascular bone marrow necrosis and cerebral fat embolism syndrome from sickle cell crisis.

Introduced predators and cavity-nesting seabirds: unexpected low level of interaction at breeding sites

The mechanisms by which introduced predators and long-lived seabirds interact and even coexist are still poorly known. Here, the interactions between the widely introduced black rat ( Rattus rattus (L., 1758)) and an endemic Mediterranean cavity-nesting seabird, the yelkouan shearwater ( Puffinus yelkouan (Acerbi, 1827)), were for the first time investigated for a set of 60 suitable breeding cavities throughout the entire breeding cycle of this seabird. Our results pointed out that rat visits to cavities were significantly higher when shearwaters had left the colony for their interbreeding exodus. Among the set of suitable breeding cavities, yelkouan shearwaters preferentially selected the deepest and the most winding cavities for breeding. Very few rat visits were recorded at the shearwater-occupied cavities and no predation event was recorded. These intriguing results reveal a low level of interaction between introduced black rats and yelkouan shearwaters, which may have facilitated their long-term coexistence for thousands of years on some Mediterranean islands.

Clozapine for the treatment of drug-induced psychosis in Parkinson's disease: results of the 12 week open label extension in the PSYCLOPS trial

OBJECTIVE

To report the results of the 12-week, prospective, open label extension of the 4-week, multicenter, placebo-controlled, double-blind PSYCLOPS (PSYchosis and CLOzapine in the treatment of Parkinsonism) trial. This extension examined the chronic safety and efficacy of clozapine in the treatment of drug-induced psychosis in Parkinson's disease (PD).

BACKGROUND

Psychosis is a serious late complication of PD and may be a harbinger to increased mortality. Clozapine, the first atypical antipsychotic, was shown in several small open label studies to improve psychosis without worsening of motor symptoms. This was recently confirmed in the double-blind PSYCLOPS trial.

METHODS

The 53 patients who completed the double-blind portion of PSYCLOPS were evaluated on their original randomized treatment (clozapine or placebo), then had study medication stopped. All were started on clozapine. The patients from both treatment groups were evaluated every 4 weeks over a 12-week period using standardized measures for psychosis and PD.

RESULTS

The mean dose of clozapine was 28.78 mg/day. Those originally treated with placebo improved significantly in Brief Psychiatric Rating Scale and clinical global scores for psychosis to the same degree as the group originally randomized to clozapine in the double-blind study. Both groups maintained their response to week 16 (end of the combined double-blind and open label portions). There was no worsening of motor features as measured by the Unified Parkinson's disease rating scale. Eighteen patients were either hospitalized or died during the trial. The most common reasons were pulmonary.

CONCLUSIONS

Low-dose clozapine is effective in treating drug-induced psychosis without worsening motor features of PD, and the response is maintained for at least 4 months. Patients with psychosis and PD were previously described as a group with high risk for morbidity and mortality. The high risk continues despite antipsychotic therapy.

A prospective, controlled study of Helicobacter pylori seroprevalence in coronary artery disease

OBJECTIVE

Recent studies have suggested that chronic infections may be a risk factor for coronary artery disease. The aim of this study was to determine whether Helicobacter pylori (H. pylori) infection was an independent risk factor for coronary artery disease.

METHODS

A total of 179 patients undergoing coronary angiography for suspected coronary artery disease were prospectively studied. Angiograms were read by experienced invasive cardiologists blinded to the results of H. pylori serology, which was determined by a validated multiwell ELISA assay.

RESULTS

A total of 121 patients (68%) had evidence of coronary artery disease, whereas 58 patients (32%) had normal coronary angiograms. Of the 121 patients with coronary artery disease, 29 had single vessel disease, 39 had double vessel disease, and 53 had triple vessel disease, respectively. There was no significant difference in seroprevalence of H. pylori infection in patients with and without coronary artery disease (p = 0.63). The odds ratio (after adjustment for other known risk factors) for coronary artery disease in H. pylori-infected subjects was 0.45 (95% CI = 0.15, 1.37; p = 0.107). In patients with coronary artery disease, H. pylori infection did not increase the likelihood of severe disease (odds ratio for triple vessel disease = 0.53; 95% CI 0.18, 1.60; p = 0.201).

CONCLUSION

H. pylori infection rates are similar in patients with normal and abnormal coronary arteries, and infection with H. pylori is not an independent risk factor for coronary artery disease. In patients who have coronary artery disease, H. pylori infection is not a risk factor for more severe disease. These data argue against a causal role for H. pylori in the pathogenesis of coronary artery disease.

A prospective, controlled trial of eight-bit, 16-bit, and 24-bit digital color images in electronic endoscopy

BACKGROUND AND STUDY AIMS

Digital color information is obtained in "bits" or parcels of information for each color (red, green, blue) of a picture. As the number of bits increases, the amount of color information increases, and more colors can be displayed on a suitable monitor. With eight bits of information, 256 colors can be displayed; with 16 bits, several thousand colors can be displayed; and with 24 bits, more than 16 million colors can be displayed. We sought to determine the minimum requirement for diagnostic-quality endoscopy images in a prospective blinded trial.

PATIENTS AND METHODS

Twenty-four bit color images were digitally acquired from the processor using a video card and a personal computer. Ten lesions were chosen to represent the gamut of lesions seen in the upper gastrointestinal tract. Images were simultaneously obtained with decreasing color information (16 and eight bits), and these served as controls. Eleven observers were the test subjects. Six endoscopy nurses, who perform color calibrations, and five endoscopists viewed the images. Eight-bit, 16-bit and 24-bit color images were coded and displayed simultaneously on a high-resolution color monitor (Supermac Technology, Sunnyvale, CA) that can display 16.8 million colors.

RESULTS

All images were considered to be of diagnostic quality by the observers, and the area of abnormality was identified and the diagnosis made in all cases. Of 110 viewings of the 24-bit image, on 45 occasions (41%) the viewers could detect no difference between it and the eight-bit and 16-bit images. In 23 (21%), the 24-bit color image was correctly recognized, and on 21 occasions (19%) the 24-bit image was incorrectly identified as eight-bit or 16-bit. Similar data were obtained with viewings of the eight-bit and 16-bit images.

CONCLUSIONS

Our results demonstrate that, with current endoscopic technology, 256 colors may be as good as 16 million. Eight-bit color is an acceptable image standard for routine endoscopy.

Endoscopic measurement of lesion size: improved accuracy with image processing

Endoscopic measurement of lesions is of great importance in the design and performance of clinical trials, as, for example, in studies of ulcer disease. Endoscopes are constructed with wide-angle lenses that significantly distort the image by creating a relative compression of points in its periphery. We have recently developed a computer program to correct the distortion of the wide-angle lens. We sought to determine the accuracy of the currently used open-biopsy forceps measurement technique and compare it to that of an image-processing technique designed to correct image distortion. The overall error of the open-biopsy forceps technique using an in vitro ulcer model was under-estimation of lesion size by 41.8% +/- 23.3%. When image processing was used to correct distortion, error was significantly decreased to 1.8% +/- 2.2% (p < 0.05). In vivo measurements were made using an inserted object of known size (coated chewing gum). The mean error of the forceps technique in vivo was 26.5% +/- 5.7% (under-estimation of size), which improved significantly to an error of 2.8% +/- 3.2% (p < 0.05) with the image-processing technique. We conclude that image processing significantly enhances the accuracy of measurement at endoscopy.