Palliative cytoreduction with low dose intravenous melphalan in patients with acute myeloid leukemia refractory to prior treatment

BACKGROUND

Hyperproliferative crises with hyperleukocytosis occur frequently in the disease course of refractory or relapsed acute myeloid leukemia (AML). Palliative cytoreduction aims to control blast count in order to avoid life-threatening complications and preserve quality of life in patients unfit for intensive treatment. In our center, low-dose intravenous melphalan is sometimes used with this intent.

METHODS

We performed a retrospective analysis of patients with AML who were treated with low-dose intravenous melphalan (15-30 mg/m²) in a palliative setting.

RESULTS

Thirty patients with AML who received low-dose melphalan (15-25 mg/m²) were identified. In total, 63 administrations of low-dose melphalan were counted. A clear cytoreductive effect (>50%) was seen within a few days in 78% of melphalan administrations. The median duration of response after an individual dose was 17 days (interquartile range [IQR] 10-26). The median overall survival was 29 days (IQR 16-73). Most common side effects were worsening pancytopenia with neutropenic fever and an increase in transfusion dependency and tumor lysis syndrome.

CONCLUSION

Intravenous low-dose melphalan is effective, quick and safe as palliative cytoreductive therapy in patients with hyperproliferative AML. It can be considered in palliative care of patients refractory to prior treatment with preserving acceptable quality of life. Our small retrospective cohort is the first to report the use of low-dose intravenous melphalan as palliative cytoreductive treatment in this population.

Flucloxacillin-induced hypokalaemia: a case report

OBJECTIVE AND IMPORTANCE

Flucloxacillin is a narrow-spectrum beta-lactam antibiotic with activity against penicillinase producing staphylococci and streptococci. Severe hypokalaemia is an uncommon, but serious adverse effect in patients treated with penicillin derivates.

CLINICAL PRESENTATION

We report a case of severe hypokalaemia in a patient treated with high dose intravenous flucloxacillin.

CONCLUSION

This case report highlights the importance of monitoring electrolytes during treatment with high dose flucloxacillin. If severe hypokalaemia is noted during treatment, this should be considered in the differential diagnosis.

Anti-MDA5 positive dermatomyositis complicated with rapidly progressive interstitial lung disease - a case report

CASE PRESENTATION

 We present a case of a 55-year-old Caucasian male with manifestations of dermatomyositis complicated with rapidly progressive interstitial lung disease (RP-ILD). Diagnosis of anti-MDA5 positive dermatomyositis was made.

DISCUSSION

 Myositis specific antibodies (MSA) can be used for diagnosis and predicting prognosis in patients with polymyositis and dermatomyositis. Anti-MDA5 positive dermatomyositis should be considered in patients presenting with dermatomyositis and a disease course resembling antisynthetase syndrome in the absence of antisynthetase autoantibodies, especially if a remarkably high ferritin is noted. Anti-MDA5 autoantibodies have been associated with RP-ILD and adverse outcome. In patients with anti-MDA5 autoantibodies, early diagnosis and aggressive immunosuppressive treatment may improve prognosis.

CONCLUSION

 This case highlights the importance of determining MSA in patients with dermatomyositis and associated interstitial lung disease, as this has implications for diagnosis, prognosis and therapy.