Resident Physician “Moonlighting” for On-call in Transfusion Medicine: Educational Impact and Preparedness for Practice

Introduction/Objective

Resident physician moonlighting is controversial and uncommon in Pathology, usually limited to anatomic pathology grossing support. Due to an acute staffing shortage in our department, we offered senior AP/ CP residents in our program a “moonlighting” opportunity involving partnership with attendings to supervise junior residents for transfusion medicine on-call (TMO) . Given the conflicting claims of educational benefit and detriment of moonlighting, we sought to evaluate impact of TMO moonlighting activities on residents' educational experience and preparedness for clinical practice.

Methods/Case Report

Residents selected for moonlighting TMO were PGY-3/4, “exceeded expectations” on their transfusion medicine rotation and had taken resident TMO. After initial “boot camp” exercises involving common TMO scenarios, they were added to the attending on-call schedule with a fair financial incentive. They were the first resource and provided in-person support for the TMO resident. Attendings were available for consultation via a secure communications platform (phone and text). After one year, residents were surveyed regarding overall experience, sense of graduated responsibility, impact of financial incentive, preparedness for future practice, and impact on day- time service commitment. "Resident In-Service Examination" (RISE) score was used to estimate impact of TMO on medical knowledge.

Results (if a Case Study enter NA)

NA.

Conclusion

Four out of the five residents took the survey. All 4 responded “definite” for positive experience, feeling of graduated responsibility and preparedness for practice. Financial incentive was assessed favorably. No resident reported an adverse impact on their daytime service responsibility. The group median score on RISE transfusion medicine 2022 was 75th percentile with median increase in 10 percentile points. As pathology moves towards sub- specialty practice, working fluency in some areas such as TMO remains a necessity for smaller group practices. Our experience (albeit with a small group of residents) suggests that TMO moonlighting activities may better prepare the residents for this unmet need.

A Novel Fusion Partner in a Case of Myeloid/Lymphoid Neoplasm with FGFR1 Rearrangement

Introduction/Objective

Myeloid/lymphoid neoplasms with rearrangement of FGFR1 are uncommon and heterogeneous group of hematological malignancies that may present as myeloproliferative neoplasm, acute myeloid leukemia, T or B lymphoblastic lymphoma/leukemia, or mixed phenotypic acute leukemia. Patients can present with lymphadenopathy, mediastinal mass, or systemic symptoms. Eosinophilia is common in peripheral blood or bone marrow. Several chromosomal rearrangements and fusion genes have been described with FGFR1 rearrangement and all of them encode an aberrant tyrosine kinase. Tyrosine kinase inhibitors may offer a prospective therapeutic approach although specific targeted therapies have yet to be established.

Methods/Case Report

We present a case of a 14-year-old male who presented with rapid neck pain and swelling. Imaging revealed a 15 x 8 x 6 cm neck mass extending into the anterior mediastinum. Laboratory evaluation revealed anemia, thrombocytopenia, and leukocytosis (41.7 K/mm3), with absolute eosinophilia and blasts of 50%. Flow cytometry of peripheral blood demonstrated a population of T-lymphoblasts comprising about 60% of the cellularity with dim CD45, cytoplasmic CD3, CD7, TdT, CD38, CD4, CD5, CD10, and CD15, supporting T-lymphoblastic leukemia/lymphoma. The patient received induction chemotherapy, and subsequent bone marrow biopsy showed morphologic remission. Six weeks from diagnosis, the patient developed a gluteal mass with an atypical T-cell infiltrate that was negative for TdT; and at 15 weeks from diagnosis, developed an enlarging abdominal mass, also with an atypical T-cell infiltrate also negative for TdT and CD1a. At that time molecular diagnostic studies of the abdominal wall mass discovered a previously unpublished ATG16L1-FGFR1 fusion, supporting myeloid/lymphoid neoplasm with FGFR1 rearrangement, T-lymphoblastic leukemia/lymphoma.

Results (if a Case Study enter NA)

NA.

Conclusion

Although a variety of translocations have been identified with FGFR1 rearrangement, the novel fusion partner ATG16L1 has not been previously reported. The case also illustrates an unusual extramedullary recurrence of the T-cell lymphoblastic leukemia/lymphoma with significant antigenic shift including loss of TdT and CD1a.

Acute Leukemias of Ambiguous Lineage presenting in Extramedullary Location – Unusual and Challenging Diagnoses: A Report of Two Cases

Introduction/Objective

Acute leukemias of ambiguous lineage are uncommon, accounting for <1% of all leukemias, and extramedullary presentations of these leukemias are rare.

Methods/Case Report

We report two cases of acute leukemia of ambiguous lineage presenting in extramedullary sites. Case 1 is a 41-year-old female who presented with right cervical lymphadenopathy and fatigue. Laboratory and imaging studies showed leukopenia, anemia, and abnormal cervical, supraclavicular, axillary, mediastinal, and abdominal pelvic lymphadenopathy. Biopsy of the axillary lymph node revealed sheets of morphologic blasts. Flow cytometry showed the blasts were of mixed phenotype, with T-cell differentiation supported by CD3 and TdT, and myeloid subpopulation supported by myeloperoxidase and lysozyme. Both these populations were negative for CD10, CD20, CD4, CD8, CD34, CD138, CD1a, CD79a. The morphology and immunophenote establish the diagnosis of T/myeloid mixed-phenotype acute leukemia, not otherwise specified. Case 2 is a 65-year-old female who presented with bilateral lower extremity weakness. Multiple lytic lesions involving the thoracic and cervical spine were detected by imaging. Biopsy of a T12 vertebral lesion revealed sheets of large malignant cells. Extensive immunohistochemical workup revealed positivity for CD45 (weak), CD4, and CD43, supporting a diagnosis of hematopoietic neoplasm of likely hematopoietic origin. Subsequent evaluation eventually led to discovery of chronic myeloid leukemia in blast phase with undifferentiated blasts, BCR-ABL1 positive, originally presenting as extramedullary acute leukemia with undifferentiated blasts.

Results (if a Case Study enter NA)

NA.

Conclusion

These cases highlight the challenges of diagnosing peripheral solid tumors of unknown origin. Extramedullary presentation of acute leukemia of ambiguous lineage are particularly challenging and, although rare, include phenotypes ranging from mixed phenotype to undifferentiated types.

An Unusual Hematologic Manifestation in a COVID-19 Patient Treated with COVID-19 Convalescent Plasma

Introduction/Objective

A subset of Chronic Lymphocytic Leukemia (CLL) patients with COVID-19 may manifest rapid elevations in lymphocyte counts and poor clinical outcomes. Here we report our observations regarding this unusual hematologic manifestation in a CLL patient after he experienced a COVID-19 convalescent plasma (CCP) transfusion reaction.

Methods/Case Report

56-year-old A Rh- male with stable, treatment-naive CLL (13q deletion positive) diagnosed three years prior was admitted for COVID-19 hypoxia. Before developing COVID-19, baseline white blood cell (WBC) count was stable (~ 64 K/ mm3). Due to worsening hypoxia he was treated with an ARh+ High Titer CCP unit, Remdesivir, tocilizumab, and dexamethasone. The Blood Bank was notified of a possible CCP reaction and performed its standard workup which was adjudicated to be a febrile TACO reaction. During this evaluation it was noted that the patient’s WBC count had initially decreased to 46 K/ mm3, but rose on HD 3, to 78.4 K/mm3 and by discharge on HD 10 had increased to 200 K/ mm3. Flow cytometry revealed a B cell CLL immunophenotype. Post discharge day (PDD) 6 he developed herpes zoster. On post-discharge day (PDD) 7 his WBC count was 124K/mm3. By PDD 77 his WBC count had returned to baseline (~50 K/mm3).

Results (if a Case Study enter NA)

NA

Conclusion

The pt’s initial drop in his WBC count followed by a gradual rise has been observed in patients with severe COVID-19 independent of CCP infusion. Lymphocytosis in a subset of CLL patients with COVID-19 has been reported (termed “COVID-19 Induced Lymphocytosis” (CIL)) and, in contrast to our patient with an improved outcome, has been associated with severe/fatal outcomes. Of note these other patients did not receive CCP. Mechanisms related to CIL are unknown. Such poor clinical outcomes heighten the need for further studies of CIL. The role of CCP in affecting this process, if any, also merits further clarification.

Signature sequences in diverse proteins provide evidence of a close evolutionary relationship between the Deinococcus-thermus group and cyanobacteria

A number of proteins have been identified that contain prominent sequence signatures that are uniquely shared by the members of the Deinococcus-Thermus genera and the cyanobacterial species but which are not found in any of the other eubacterial or archaebacterial homologs. The proteins containing such sequence signatures include (1) the DnaJ/Hsp40 family of proteins, (2) DNA polymerase I, (3) the protein synthesis elongation factor EF-Tu, and (4) the elongation factor EF-Ts. A strong affinity of the Deinococcus-Thermus species to cyanobacteria is also seen in the phylogenetic trees based on Hsp70 and DnaJ sequences. These results provide strong evidence of a close and specific evolutionary relationship between species belonging to these two eubacterial divisions.