Diagnosis, management, and outcomes of immune checkpoint inhibitor induced acute interstitial nephritis: A single-center experience

BACKGROUND

Immune checkpoint inhibitor (ICI)-associated acute interstitial nephritis (AIN) is a recognized complication of immunotherapy (IO), but literature on its management and outcomes is limited.

METHODS

We retrospectively reviewed patients who received ICIs and developed biopsy-proven or clinically-suspected ICI-associated AIN at the University of Virginia Comprehensive Cancer Center from 2012-2023. We analyzed baseline characteristics and clinical outcomes, including treatment interruption and rechallenge rates. Acute kidney injury (AKI) was defined as a ≥ 1.5-fold increase in baseline creatinine under seven days, a two-fold increase above the upper limit of normal, or an increase by ≥0.3 mg/dL. Kidney function returning to within 0.3 mg/dL or less than twice baseline was considered complete (CRc) and partial (PRc) recovery, respectively.

RESULTS

We identified 12 cases of ICI-AIN: four by biopsy (33%) and eight (67%) by clinical suspicion. Two patients received anti-CTLA-4 and anti-PD1, six received anti-PD1 alone, and four received chemo-immunotherapy. The majority (58%) of patients developed AIN within the first 5 cycles. Eight patients developed ≥ Grade 3 AKI, and six developed multiple irAEs. ICI was permanently discontinued in seven patients (58%) and temporarily interrupted in four (30%). The CRc and PRc rates were 67% and 8%, respectively. Upon AIN onset, the best disease response was stable disease in five patients, partial response in three, and progressive disease in three. Median overall survival was 4.87 years, and progression-free survival was 1.5 years.

CONCLUSIONS

Rechallenge with IO after kidney irAE may be possible in some patients but requires careful evaluation on an individual basis.

Patient with mediastinal carcinoma of unknown primary with RET fusion achieves durable response with RET inhibition

Selective RET inhibitors have shown promise in thyroid cancer (TC) and nonsmall cell lung cancer (NSCLC) harboring RET fusions on next-generation sequencing (NGS), although rarity of the rearrangement has led to limited data for certain tumor types, such as carcinoma of unknown primary. We present a 65-year-old female with no history of malignancy, smoking or radiation exposure, who was found to have an anterior mediastinum malignancy of unknown primary, with metastases to supraclavicular lymph nodes. Core biopsy of the mediastinum revealed poorly differentiated carcinoma, while a biopsy of the thyroid revealed atypia of indeterminate significance (Bethesda III). PD-L1 immunohistochemistry was positive (90%), and liquid NGS revealed mutations in TP53 and the TERT promoter (c.-124C>T), as well as a CCDC6-RET fusion. This genetic profile resembled an anaplastic TC vs. NSCLC primary, although thymic primary and poorly differentiated TC remained on the differential. The patient was initiated on selpercatinib, which was held after 3 weeks due to thrombocytopenia and hypertension. At a reduced dosage, patient developed transaminitis, and selpercatinib was switched to pralsetinib. Brain MRI showed a nonenhancing temporal lobe signal abnormality, which on biopsy proved to be glioblastoma (GBM) with TERT promoter c.-124C>T mutation and FGFR3-TACC3 fusion by NGS. Pralsetinib was held during adjuvant chemoradiation for the GBM, and again for 4 weeks due to pneumonitis that resolved with steroids, and pralsetinib was restarted at a reduced dose. The patient has since demonstrated a stable reduction of the mediastinal mass for >15 months with RET inhibition therapy, despite several treatment interruptions.

von Willebrand disease: A guide for the internist

von Willebrand disease (VWD), the most common inherited bleeding disorder, results when patients either do not make enough von Willebrand factor (VWF) or make defective VWF. The pathophysiology of this disorder is complex but needs to be understood to interpret the diagnostic tests. Most patients have mild to moderate symptoms and can be adequately counseled and managed by a general internist, but some need to consult a hematologist. We review the pathophysiology of VWD, its subtypes, common presentations of each subtype, diagnostic testing, and management of mild as well as severe clinical manifestations of VWD.

Impact of Opioid Use on Duration of Therapy and Overall Survival for Patients with Advanced Non-Small Cell Lung Cancer Treated with Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICI) have significantly improved outcomes in advanced non-small cell lung cancer (NSCLC). We evaluated the effect of opioid use on outcomes in patients receiving ICI either alone or with chemotherapy. We conducted a retrospective review of 209 patients with advanced NSCLC who received an ICI at the University of Virginia between 1 February 2015 and 1 January 2020. We performed univariate and multivariate analyses to evaluate the impact of opioid use on duration of therapy (DOT) and overall survival (OS). Patients with no or low opioid use (n = 172) had a median DOT of 12.2 months (95% CI: 6.9-17.4) compared to 1.9 months (95% CI: 1.8-2.0) for those with high opioid use (n = 37, HR 0.26 95% CI: 0.17-0.40, p < 0.001). Patients with no or low opioid use had a median OS of 22.6 months (95% CI: 14.8-30.4) compared to 3.8 months (95% CI: 2.7-4.9) for those with high opioid use (HR 0.26 95% CI: 0.17-0.40 p < 0.001). High opioid use was associated with a shorter DOT and worse OS. This difference remained significant when accounting for possible confounding variables. These data warrant investigation of possible mechanistic interactions between opioids, tumor progression, and ICIs, as well as prospective evaluation of opioid-sparing pain management strategies, where possible.

Diagnosis and management of gastrointestinal SMARCA4-deficient undifferentiated tumors

SMARCA4-deficient undifferentiated tumors are a rare clinical entity with an aggressive clinical course, poor prognosis, and no standard-of-care therapeutic approach. These have most frequently been documented in the lung and thoracic cavity. There is a growing body of evidence for the role of immunotherapy in SMARCA4-deficient lung cancer, a disease process that historically does very poorly with cytotoxic chemotherapy alone. We present three cases where the primary tumors were instead found within the gastrointestinal system: two originating from the small bowel and one from the esophagus. In all three cases, clinical response was seen with pembrolizumab therapy, with two of the three patients receiving long-term benefit. Our series suggests that anti-PD1 immunotherapy may have promising efficacy for undifferentiated carcinomas of the gastrointestinal tract with SMARCA4 deficiency.

Improved survival for stage IV sinonasal small cell neuroendocrine carcinoma treated with chemotherapy and anti-PD-L1 therapy

Small cell carcinoma neuroendocrine type (SCCNET) is a rare tumour of the head and neck. Due to its infrequency, a paucity of data exists on optimal treatment, and the current paradigm for advanced SCCNET mirrors that of extensive small cell lung cancer. Increasingly, the treatment for extrapulmonary small cell carcinomas like SCCNET has incorporated immune checkpoint inhibitors (ICIs), although the utility of ICIs is not fully understood. We present a case of stage IVC sinonasal SCCNET in a woman in her 90s, who experienced eyelid swelling and unintentional weight loss. After diagnostic work-up, she was treated with etoposide, carboplatin and atezolizumab with a complete response to therapy. The patient had one episode of inflammatory polyarthropathy which resolved with steroids but otherwise tolerated treatment well and is now living with an overall survival of greater than 27 months. This case highlights the long-term efficacy of combination ICIs and chemotherapy in the treatment of SCCNET.

The human ribosome-associated complex suppresses prion formation in yeast

Many human diseases are associated with the misfolding of amyloidogenic proteins. Understanding the mechanisms cells employ to ensure the integrity of the proteome is therefore a crucial step in the development of potential therapeutic interventions. Yeast cells possess numerous prion-forming proteins capable of adopting amyloid conformations, possibly as an epigenetic mechanism to cope with changing environmental conditions. The ribosome-associated complex (RAC), which docks near the ribosomal polypeptide exit tunnel and recruits the Hsp70 Ssb to chaperone nascent chains, can moderate the acquisition of these amyloid conformations in yeast. Here we examine the ability of the human RAC chaperone proteins Mpp11 and Hsp70L1 to function in place of their yeast RAC orthologues Zuo1 and Ssz1 in yeast lacking endogenous RAC and investigate the extent to which the human orthologues can perform RAC chaperone activities in yeast. We found that the Mpp11/Hsp70L1 complex can partially correct the growth defect seen in RAC-deficient yeast cells, although yeast/human hetero species complexes were variable in this ability. The proportion of cells in which the Sup35 protein undergoes spontaneous conversion to a [PSI+ ] prion conformation, which is increased in the absence of RAC, was reduced by the presence of the human RAC complex. However, the toxicity in yeast from expression of a pathogenically expanded polyQ protein was unable to be countered by the human RAC chaperones. This yeast system can serve as a facile model for studying the extent to which the human RAC chaperones contribute to combating cotranslational misfolding of other mammalian disease-associated proteins.

Abstract P2-13-01: Enrollment Trends Among Patients With Breast Central Nervous System Metastasis in Active Clinical Trials

Background: Breast cancer is the second leading cause of solid tumor brain metastasis. Up to 16% of patients with metastatic breast cancer (mBC), and 50% patients with HER2+ metastatic breast cancer will develop central nervous system (CNS) metastasis overtime. Prognosis in these patients is dismal with a median overall survival of 2-15 months. Despite advances in systemic therapy of mBC, treatment options for patients with breast cancer brain metastasis (BCBM) remain limited. Although newer approaches to treat BCBM are imminently needed, BCBM patients have traditionally been excluded from clinical trials. We aimed to examine the current state of BCBM-related enrollment in ongoing prospective systemic therapy clinical trials for mBC. Methods: We performed a systematic search of the clinicaltrials.gov website on May 1, 2022 to characterize current trends in clinical trial enrollment for BCBM patients in ongoing interventional trials using the key search term “Breast Cancer”. Trial search was further limited to “open” and “interventional studies”. Data was abstracted and verified by two independent researchers. Trials were excluded if they were specific for other disease types, did not include a systemic anticancer pharmaceutical, or excluded advanced/metastatic disease. Inclusion of active CNS disease [BCMB and leptomeningeal disease (LMD)] and exclusion of CNS disease were the co-primary end points. Covariates of interest were gender, location (US, international or both), disease site (breast cancer specific vs multi-disease trials), therapy category (immunotherapy (IO), targeted therapy, endocrine therapy, chemotherapy, or combination) and sponsor type. Logistic regression was used to model inclusion of active CNS disease. Results: A total of 1720 trials were identified, and 576 trials met the inclusion criteria. 179 (31.6%) were phase I, 129 (22.4%) were phase I/II, 196 (34.0%) were phase II, 60 (10.4%) were phase III and 9 (1.6%) were phase IV. 347 (60.4%) were breast cancer specific and 229 (39.6%) were multi-site trials. 66 (11.5%) trials were specific for HER-2+ cancer and 70 (12.1%) were triple negative breast cancer specific. 238 (41.3%) trials were US only and 290 (50.3%) were pharmaceutical industry sponsored. Overall, only 29 trials (5%) included patients with any form of BCBM and only 11 trials (1.9%) allowed patients with LMD. 12 (2.1%) trials allowed patients with treated BCBMs only. In univariate models, breast cancer only trials (OR 4.07, 95% CI 1.77-9.36, p= 0.0009), trials excluding men (OR 1.97, 95% CI 1.03-3.77, p=0.0412), non-IO therapy trials (non-IO vs IO OR 3.57, 95% CI 1.08-11.82, p=0.369), and non-pharmaceutical industry sponsored trials (OR 2.65, 95% CI 1.34-5.22, p =0.0049) were more likely to include patients with active CNS disease. Additionally, inclusion of LMD (OR 7.85, 95% CI 2.19-28.17, p = 0.0016) was a significant predictor of inclusion of active CNS disease. In a combined model, disease site remained significant (breast only vs multi-site OR 4.07, 95% CI 1.77-9.36, p = 0.0009). Conclusion: The vast majority of the ongoing breast cancer clinical trials continue to exclude patients with breast cancer brain metastasis. With an increasing prevalence of breast cancer brain metastasis, evaluating intracranial efficacy of novel therapies early on in drug development remains an area of urgent unmet need.

Citation Format: Omar Elghawy, Walter Banfield, John Wang, Bethany Horton, Varinder Kaur. Enrollment Trends Among Patients With Breast Central Nervous System Metastasis in Active Clinical Trials [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-13-01.

Complete Response of Triple-Negative Metaplastic Carcinoma of the Breast Using Pembrolizumab

Metaplastic breast cancer (MpBC) is a rare form of breast malignancy with a poor prognosis and limited treatment guidance. Here, we report on a case of triple-negative MpBC that was successfully treated following the Keynote-522 clinical algorithm using pembrolizumab, paclitaxel, carboplatin, adriamycin, and cyclophosphamide in a neo-adjuvant fashion. The radiographic and histologic findings of the tumor are reviewed here along with the treatment regimen and response. No major toxicities associated with pembrolizumab were observed in this case. This case report serves as an example of complete pathological response of triple-negative MpBC with pembrolizumab plus chemotherapy and demonstrates the need for further research on chemoimmunotherapy for MpBC.

Current State of Platelet-rich Plasma in the Treatment of Rheumatic Disease: A Retrospective Review of the Literature

INTRODUCTION

Rheumatic diseases are a spectrum of autoimmune or inflammatory diseases that cause damage to the musculoskeletal system as well as vital organs, such as the heart, lungs, kidneys, and central nervous system.

METHODS

The study of rheumatic disease has made great progress in the understanding and management of these conditions in the last few decades using disease-modifying antirheumatic drugs and synthesized biological immunomodulating therapies. However, one potential treatment that has not been well investigated in rheumatic disease is platelet-rich plasma (PRP). PRP is proposed to facilitate the healing of injured tendons and ligaments through a variety of mechanisms, including mitogenesis, angiogenesis and macrophage activation via cytokine release, although its exact mechanism is unclear.

RESULT

There has been a great deal of work in determining the exact preparation method and composition of PRP for regenerative purposes in orthopedic surgery, sports medicine, dentistry, cardiac surgery, pediatric surgery, gynecology, urology, plastic surgery, ophthalmology, and dermatology. Despite this, there is a paucity of research on the impact of PRP on rheumatic disease.

CONCLUSION

This study aims to summarize and evaluate the current research concerning the use of PRP in rheumatic disease.

Synthesis of 7-Aminocoumarins from 7-Hydroxycoumarins via Amide Smiles Rearrangement

N-Substituted 7-aminocoumarins can be synthesized from readily available 7-hydroxycoumarins via alkylation with α-bromoacetamides and subsequent tandem O → N Smiles rearrangement-amide hydrolysis. The key rearrangement sequence proceeds under mild conditions to provide convenient access to various N-alkyl and N-aryl products in moderate to high yields. The process is operationally simple, inexpensive, transition-metal-free, and can be telescoped into a one-pot process.

CLRM-11 CURRENT STATE OF CLINICAL TRIALS FOR PATIENTS WITH MELANOMA BRAIN METASTASES

INTRODUCTION

Clinical trials have traditionally excluded patients with melanoma brain metastasis (MBM), despite evidence of CNS activity of systemic therapy. The true extent of variation in MBM-related enrollment criteria in ongoing melanoma clinical trials has not been evaluated.

METHODS

A systematic search of clinicaltrials.gov website was performed to characterize trends in clinical trial enrollment of MBM patients in interventional drug trials. Trial data search was limited to “open”, “interventional studies” and advanced stage melanoma in adult patients. Logistic regression was used to model inclusion of active MBMs. Covariates considered were phase of study, location, therapy type, melanoma specific, and sponsor category

RESULTS

Of a total of 475 trials identified, 365 met inclusion criteria. 230 (63.0%) were phase I, 119 (32.6%) were phase II, 14 (3.8%) were phase III and 2 (0.5%) were phase IV trials. 184 (50.4%) were pharmaceutical industry sponsored, 183 (50.1%) were specific for melanoma. Forty-seven (12.8%) trials strictly excluded brain metastasis and 173 (47.3%) strictly excluded leptomeningeal disease (LMD). 261 (71.5%) trials allowed patients with previously treated MBM, and 73 (20.0%) allowed patients with active MBMs. No explicit mention of CNS metastasis was made in 13.6% of trials and no mention of LMD was made in 43.8% trials. In univariate models, trials not employing immunotherapy (odds ratio 2.23; 95% CI: 1.2, 4.3; p = 0.0174) and non-pharma trials (odds ratio 1.98; 95% CI 1.0, 3.9; p= 0.0461) were twice as likely to include MBM patients. In a combined model, only therapy type remained significant at the α=0.05 level.

CONCLUSION

Despite the evidence of CNS activity of immunotherapy in randomized trials, only 20% ongoing trials are enrolling patients with active MBMs. Efforts should be made to tailor future clinical trial designs to include MBM patients to assess CNS activity of systemic therapeutics early on in drug development.

LGL leukemia patients exhibit substantial protective humoral responses following SARS-CoV-2 vaccination

Large granular lymphocyte leukemia is a rare chronic lymphoproliferative disorder of cytotoxic cells. Other hematological malignancies such as CLL and multiple myeloma have been associated with poor vaccination response and markedly increased severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mortality rates, specifically in patients who have undergone immunosuppressive therapy. Given the immunosuppressive therapies often used to treat the disease, large granular lymphocytic (LGL) patients may be especially vulnerable to SARS-CoV-2 infection. A questionnaire was sent to all patients in the LGL Leukemia Registry at the University of Virginia (UVA) to obtain information on vaccination status, type of vaccine received, side effects of vaccination, patient treatment status before, during, and after vaccination, antibody testing, history of coronavirus disease 2019 (COVID-19) infection, and presence or absence of booster vaccination. Antibody testing of 27 patients who had quantitative SARS-CoV-2 Spike Protein IgG levels determined by University of Virginia medical laboratories via the Abbott Architect SARS-CoV-2 IgG II assay were collected. The assay was scored as reactive at a threshold of ≥50.0 AU/mL or nonreactive with a threshold of <50.0 AU/mL. LGL patients without treatment as well as patients who held treatment prior to their vaccination have a robust humoral response to SARS-CoV-2 vaccines. Patients who did not hold their immunosuppressive treatments have signifigantly diminished vaccine response compared to those who held their immunosuppressive treatment. Our findings support a dual strategy of pausing immunotherapy during the vaccination window and administration of the SARS-CoV-2 booster to all LGL leukemia patients to maximize protective antibodies.

Impact of COVID-19 on emergency department management of stroke and STEMI. A narrative review

The novel coronavirus of 2019 (COVID-19) has resulted in a global pandemic; COVID-19 has resulted in significant challenges in the delivery of healthcare, including emergency management of multiple diagnoses, such as stroke and ST-segment myocardial infarction (STEMI). The aim of this study was to identify the impacts of the COVID-19 pandemic on emergency department care of stroke and STEMI patients. In this study a review of the available literature was performed using pre-defined search terms, inclusion criteria, and exclusion criteria. Our analysis, using a narrative review format, indicates that there was not a significant change in time required for key interventions for stroke and STEMI emergent management, including imaging (door-to-CT), tPA administration (door-to-needle), angiographic reperfusion (door-to-puncture), and percutaneous coronary intervention (door-to-balloon). Potential future areas of investigation include how emergency department (ED) stroke and STEMI care has adapted in response to different COVID-19 variants and stages of the pandemic, as well as identifying strategies used by EDs that were successful in providing effective emergency care in the face of the pandemic.

Effect of surgical modality on visual outcomes for young patients with primary rhegmatogenous retinal detachments: a retrospective cohort study

Objective

To examine outcomes of different surgical modalities for correcting primary rhegmatogenous retinal detachments in patients younger than 50 years of age.

Methods and analysis

A single-centre, retrospective, cohort study of 754 patients who underwent retinal surgery at the University of Virginia Hospital between 1 July 2012 and 1 July 2020 was conducted. Exclusion criteria were patients less than 18 or over 50 years of age, repeat detachments, second eyes of patients with bilateral detachments and follow-up less than 3 months. A multivariate regression model was used to compare overall outcomes in patients.

Results

86 patients met inclusion criteria and of those, 38 (44%) underwent vitrectomy, 22 (26%) underwent scleral buckling, 13 (15%) underwent pneumatic retinopexy and 13 (15%) underwent combined scleral buckle and vitrectomy repair. Comparison of eye-level parameters among the procedure groups shows difference with respect to macular involvement (p<0.05) but not regarding clock hour involvement or giant tear status (p>0.05). Preoperative visual acuity was superior in the scleral buckle group compared with vitrectomy (p<0.001). Mean postoperative visual acuity improved with all procedures and all repair procedures had comparable rates of complication. The mean overall anatomical success rate was 73% (n=63) and comparable among all modalities.

Conclusions

Vitrectomy, scleral buckle, pneumatic retinopexy or combined procedures are viable repair options for rhegmatogenous retinal detachments in patients younger than 50 years of age. Selection of the repair modality should be guided on baseline clinical features of the patient and detachment.

Genomic landscape of TCRαβ and TCRγδ T-large granular lymphocyte leukemia

Large granular lymphocyte (LGL) leukemia comprises a group of rare lymphoproliferative disorders whose molecular landscape is incompletely defined. We leveraged paired whole-exome and transcriptome sequencing in the largest LGL leukemia cohort to date, which included 105 patients (93 T-cell receptor αβ [TCRαβ] T-LGL and 12 TCRγδ T-LGL). Seventy-six mutations were observed in 3 or more patients in the cohort, and out of those, STAT3, KMT2D, PIK3R1, TTN, EYS, and SULF1 mutations were shared between both subtypes. We identified ARHGAP25, ABCC9, PCDHA11, SULF1, SLC6A15, DDX59, DNMT3A, FAS, KDM6A, KMT2D, PIK3R1, STAT3, STAT5B, TET2, and TNFAIP3 as recurrently mutated putative drivers using an unbiased driver analysis approach leveraging our whole-exome cohort. Hotspot mutations in STAT3, PIK3R1, and FAS were detected, whereas truncating mutations in epigenetic modifying enzymes such as KMT2D and TET2 were observed. Moreover, STAT3 mutations co-occurred with mutations in chromatin and epigenetic modifying genes, especially KMT2D and SETD1B (P < .01 and P < .05, respectively). STAT3 was mutated in 50.5% of the patients. Most common Y640F STAT3 mutation was associated with lower absolute neutrophil count values, and N647I mutation was associated with lower hemoglobin values. Somatic activating mutations (Q160P, D170Y, L287F) in the STAT3 coiled-coil domain were characterized. STAT3-mutant patients exhibited increased mutational burden and enrichment of a mutational signature associated with increased spontaneous deamination of 5-methylcytosine. Finally, gene expression analysis revealed enrichment of interferon-γ signaling and decreased phosphatidylinositol 3-kinase-Akt signaling for STAT3-mutant patients. These findings highlight the clinical and molecular heterogeneity of this rare disorder.

Effect of surgical timing in 23-g pars plana vitrectomy for primary repair of macula-off rhegmatogenous retinal detachment, a retrospective study

Background

Rhegmatogenous retinal detachment (RRD) is a common, potentially blinding ocular pathology that is considered a surgical emergency. Macular involvement has been identified as a major negative prognostic indicator for visual recovery after RRD correction. It is not currently clear whether early intervention improves visual outcomes, and in practice, there are potential disadvantages to performing early surgery for fovea-involving RRD. Such disadvantages include inadequate assessment of coexisting comorbidities, increased rate of complications related to poorly trained staff or tired surgeons, and anesthetic risk.

Methods

A single-center, retrospective, cohort study of patients who underwent repair of macula-involving rhegmatogenous retinal detachment at the University of Virginia was performed. Variables collected included patient demographics, ocular history, clinical characteristics, and post-operative complications. Patients were excluded if they had a history of congenital or acquired pathology with an effect on visual function, bilateral or repeat rhegmatogenous detachment, age less than 18 years, follow up duration less than 6 months, or if they were repaired using scleral buckle, pneumatic retinopexy, 25- or 27-gauge pars plana vitrectomy, or any combination of these techniques. A multivariate regression model was used to compare overall outcomes such as post-operative visual acuity, intra-ocular pressure, retina attachment status, and complications among patients of differing timing of surgical repair. These analyses were adjusted for clinical factors known or considered to be associated with worse prognosis in rhegmatogenous retinal detachment.

Results

A total of 104 patients undergoing 23-gauge vitrectomy for repair of macula involving rhegmatogenous retinal detachments were included in this study with mean follow up period 17.9 ± 14.1 months. Early surgical repair (< 48 h) was pursued in 26 patients, moderately delayed surgical repair (3–7 days), was performed in 29 patients and late surgical repair (> 7 days) in 49 patients. Our analysis showed no difference in post-operative visual acuity between patients with detachments undergoing early versus moderately delayed repair of RRD. However, mean visual acuity differed between patients undergoing early versus late repair at 3, 6, and 12 months. No significant difference was observed in post-operative complications between the three surgical timepoints including cataract formation, development of glaucoma and re-detachment rate. Use of 360 laser was found to be protective against re-detachment overall (OR 6.70 95% CI 1.93–23.2).

Conclusions

These findings indicate that a moderate delay of 3–7 days from symptom onset for repair of macula-involving retinal detachment may be a safe approach as there are no differences in terms of visual acuity or post-operative complications compared to early repair within 48 h. Delaying surgery for > 7 days however is not recommended due to the loss of recovery of visual acuity observed in this study. Use of 360 laser may prevent risk of re-detachment after primary repair.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02364-4.

Minimal Change Disease Secondary to Graft-versus-Host Disease after Allogeneic Hematopoietic Cell Transplant for Myelodysplastic Syndrome

Chronic graft-versus-host disease (cGVHD) is a leading cause of non-relapse mortality in allogeneic hematopoietic cell transplant (HCT) recipients. While the current standard of care is proactive in detecting cGVHD in the lungs, liver, and skin, cGVHD involving kidneys is an underrecognized and likely underdiagnosed cause of post-HCT renal dysfunction. Nephrotic syndrome (NS) is a very rare complication of HCT that is postulated to be a glomerular manifestation of cGVHD. Herein, we report 2 cases of post-HCT minimal change disease likely secondary to cGVHD. In both cases, the onset of NS coincided with tapering of calcineurin inhibitors, and 1 patient had previously been diagnosed with cGVHD of the lungs. One patient was treated with corticosteroids alone and the other with a corticosteroids and tacrolimus. Complete, sustained remission was achieved in both cases. Our cases illustrate the implications of the association between cGVHD and post-HCT NS for patient care, including the importance of obtaining a renal biopsy to establish an accurate histopathological diagnosis and guide-appropriate treatment.

Multiple evanescent white dot syndrome-like reaction associated with ipilimumab and nivolumab immune checkpoint inhibitor therapy for metastasis of choroidal melanoma

PURPOSE

To present a rare case of multiple evanescent white dot syndrome (MEWDS)-like presentation associated with immune checkpoint inhibitor therapy for metastatic choroidal melanoma.

OBSERVATIONS

A 67-year-old non-myopic Caucasian female presented with bilateral worsening vision, flashes, and floaters after receiving two doses of ipilimumab and nivolumab for metastatic class 2 peripheral choroidal melanoma. Fundus imaging of the right eye revealed hypopigmented, extra-foveal scattered chorioretinal lesions with foveal granularity. Fluorescein angiogram and autofluorescence of the right eye demonstrated corresponding hyperfluorescent and hyperautofluorescent lesions in a wreath-like configuration. Optical coherence tomography of the right eye revealed subretinal fluid. Due to concurrent systemic side effects, checkpoint inhibitor therapy was paused and the patient was started on oral prednisone. At her one month follow up visit, her vision in her right eye returned to baseline and subretinal fluid resolved.

CONCLUSIONS

This is the first reported case of a MEWDS-like chorioretinopathy after two cycles of ipilimumab/nivolumab therapy for metastatic choroidal melanoma. As immune checkpoint inhibitor therapy is still an evolving field, more research is needed to characterize ocular side effect profiles of these agents.

Successful Treatment of Myxedema Coma Using Liothyronine in the Setting of Adrenal Crisis

Background: Myxedema coma (MC) represents severe decompensated hypothyroidism and is associated with mortality rates up to 50%. It is precipitated by an acute event which disrupts compensatory mechanisms present in severe hypothyroidism. Treatment includes IV levothyroxine (LT4) with consideration of liothyronine (LT3) therapy and management of any underlying stressor. Here we present a case of MC and adrenal crisis due to pituitary dysfunction successfully treated with IV LT4 and LT3. Case: A 55-year-old female with no pertinent medical history presented with two weeks of shortness of breath, anorexia, fatigue, and unexplained falls. Her initial vital signs were notable for a blood pressure of 86/60, temperature of 36.3 °C, heart rate of 59, SpO2 of 86 on room air, and respiratory rate of 21. Exam was notable for altered mentation, respiratory distress, decreased bowel sounds, and edematous facies. Initial serum studies were notable for sodium of 133 mmol/L (135-145 mmol/L), blood glucose of 50 mg/dL (74-99 mg/dL), TSH of 2.1 mIU/L (0.45-4.50 mIU/L), and blood gas showed pH of 7.27 and PaCO2 of 84.7 mmHg. She was intubated, started on vasopressors, and IV hydrocortisone 100 mg was administered. Her pretreatment serum cortisol was unmeasurable (below 0.5 mcg/dL) and ACTH resulted at 2.0 pg/mL (7-63 pg/mL). Despite hydrocortisone 50 mg q8h, her vitals worsened with HR to 40 bpm and temperature to 34.4 °C. Given concerns for MC, free and total T4 tests were obtained and both were undetectable (below 0.4 ng/dL and 4.0 ug/dL, respectively), so 300 mcg IV LT4 was administered. The next day, the patient’s vasopressor requirement increased, so 5 mcg IV LT3 q8h was added and IV LT4 was maintained at 100 mcg/day. Total T4 and T3 were measured daily and increased into the reference range over the course of 8 days and 2 days, respectively. LT3 was discontinued after 8 days and LT4 was converted to oral regimen of 125 mcg LT4 (weight expected 115 mcg) on day 14 after extubation; her hydrocortisone was tapered to a daily total of 30 mg PO. An MRI of pituitary showed an empty sella with a thin rim of normal appearing tissue without other lesions. The patient later denied any history of post-partum hemorrhage, idiopathic intracranial hypertension, pituitary surgery, radiation, or trauma. She is currently doing well on LT4 and hydrocortisone replacement. Conclusion: This case highlights the successful use of combined LT4 and LT3 in the treatment of MC with concomitant adrenal crisis. LT3 therapy may have been particularly beneficial in this case as conversion of T4 to T3 may be limited in setting of severe illness and high-dose glucocorticoid administration. Limited observational literature suggests that LT3 use can have clinical benefit, although excessive LT3 dosing may be associated with increased mortality. Further research is required to elucidate the benefits of empiric LT3 use in MC with concurrent adrenal insufficiency.

Successful treatment of metastatic pancreatoblastoma in an adult with autologous hematopoietic cell transplant

BACKGROUND

Pancreatoblastoma is a rare pediatric malignant neoplasm characterized by its histological resemblance to fetal pancreatic tissue and poor clinical outcomes. Preoperative diagnosis of the neoplasm is difficult due to its rarity, variable clinical presentation, and its lack of distinct laboratory markers. Current mainstay of treatment is surgical resection of the tumor, although a standard of care has not yet been established.

METHODS

Data were collected on one patient admitted to the University of Virginia Hospital System. Radiology, hematopoietic cell transplant, and biopsy data were collected according to the best clinical practice.

RESULTS

Herein, we describe the case of an adult patient with pancreatoblastoma treated with high-dose chemotherapy and autologous peripheral blood hematopoietic cell transplantation. To the authors' knowledge, this is the first documented successful treatment of pancreatoblastoma using autologous hematopoietic cell transplantation in the United States, and the first successful treatment in an adult patient worldwide.

CONCLUSIONS

While it is difficult to draw conclusions based on a single case, we would like to highlight the success of this treatment modality in the management of our patient with a 51-month remission and open further discussion into exploring the use of autologous hematopoietic cell transplantation for pancreatoblastoma. Our patient is currently living 57 months after diagnosis despite the average survival rate being less than 18 months.

Cytodiagnosis and protein typing of amyloid from a vitreous washing: initial diagnostic workup of hereditary amyloidosis

Hereditary amyloidosis is a challenging but critical diagnosis, with serious implications with regard to treatment and disease surveillance for both patients and their families. Systemic symptomology is often vague. As vitreous amyloid deposition is strongly linked to the systemic, hereditary disease, its cytodiagnosis in the vitreous may be the incipient finding of hereditary amyloidosis. We describe a 64-year-old man with a history of heart disease and peripheral neuropathy who presented with asymmetric visual disturbances and vitreous opacities, leading to diagnostic vitrectomy. Amyloid was identified on a ThinPrep slide of the vitreous sample via Congo red stain. Creation of a cell block from the residual ThinPrep sample allowed for amyloid protein typing, identifying ATTR (transthyretin)-type amyloid and strongly suggesting hereditary amyloidosis. Subsequent sequencing of the patient's TTR gene identified a pathogenic variant that is associated with autosomal dominant hereditary transthyretin-mediated amyloidosis.