Acute adult T-cellleukemia/lymphoma (ATLL) is a hematologic malignancy that usually entails a poor prognosis; median survival is only six months. Significant immunosuppression is commonly seen in these patients. Lung involvement in ATLL is usually documented either radiographically or as an autopsy finding. Few proven cases of ante mortem extensive lung infiltration have been described in the scientific literature. We present a fatal case of acute respiratory failure as a result of histologically proven lung infiltration by malignant lymphocytes in a patientwith acuteATLL. Although the most common cause of death i n patients with ATLL is respiratory failure in the setting of an infectious process, it should be kept in mind that patients with ATLL with acute respiratory failure may have malignant lung infiltration as a potential cause.
Data on patient-related factors associated with pneumothorax among critically ill patients with COVID-19 pneumonia is limited. Reports of spontaneous pneumothorax in patients with coronavirus disease 2019 (COVID-19) suggest that the COVID-19 infection could itself cause pneumothorax in addition to the ventilator-induced trauma among mechanically ventilated patients. Here, we report a case series of five mechanically ventilated patients with COVID-19 infection who developed pneumothorax. Consecutive cases of intubated patients in the intensive care unit with the diagnosis of COVID-19 pneumonia and pneumothorax were included. Data on their demographics, preexisting risk factors, laboratory workup, imaging findings, treatment, and survival were collected retrospectively between March and July 2020. Four out of five patients (4/5; 80%) had a bilateral pneumothorax, while one had a unilateral pneumothorax. Of the four patients with bilateral pneumothorax, three (3/4; 75%) had secondary bacterial pneumonia, two had pneumomediastinum and massive subcutaneous emphysema, and one of these two had an additional pneumoperitoneum. A surgical chest tube or pigtail catheter was placed for the management of pneumothorax. Three out of five patients with pneumothorax died (3/5; 60%), and all of them had bilateral involvement. The data from these cases suggest that pneumothorax is a potentially fatal complication of COVID-19 infection. Large prospective studies are needed to study the incidence of pneumothorax and its sequelae in patients with COVID-19 infection.
Introduction: Leukemic meningitis (LM) is a relatively rare central nervous system (CNS) complication in the era of induction protocols with CNS prophylaxis. We describe a patient with LM as the initial presentation of Acute B-lymphoblastic leukemia (B-ALL). Case Presentation: A 59-year-old female with no significant past medical history presented with 2 weeks of progressive weakness and altered mental status. On examination, she was tachypneic, tachycardic and hypotensive with a systolic blood pressure of 80 mm Hg. An arterial blood gas revealed a pH of 6.8 with a bicarbonate level of 8. She was intubated and started on vasopressors after initial fluid resuscitation. Laboratory investigation showed hemoglobin of 2 mg/dl, thrombocytopenia, leucocytosis of 96000 cell/dl including 43% atypical cells and severe metabolic acidosis with a lactate of 23.6. Chest radiograph showed bilateral patchy consolidation. A lumbar puncture showed 23 WBCs and 80% blast cells. Subsequently, flow cytometry of the peripheral blood showed 80-85% blast cells positive for Tdt, CD-19 and CD-20. Computed tomography (CT) of the chest and abdomen was negative for significant lymphadenopathy. Patient was diagnosed with acute B-cell lymphoblastic leukemia with leukemic meningitis and septic shock secondary to bilateral pneumonia. She was treated with intrathecal methotrexate and prednisone. Patient responded well to induction chemotherapy with Vincristine and was discharged after 2 months of hospitalization. Currently she is undergoing her second phase of consolidation chemotherapy. Discussion: Meningitis in leukemia may result from direct infiltration such as leukemic meningitis, subarachnoid hemorrhage, chemical (following intrathecal chemotherapy) or infectious [1]. Leukemic meningitis may be seen at diagnosis (3-5% patients with ALL) or at relapse, even with prior CNS prophylaxis. Malignant cells are thought to enter the CNS by hematogenous spread, direct extension from adjacent bone metastases, by centripetal growth along neurovascular bundles or spread from bone marrow via the intervertebral venous plexus [2].The diagnosis of CNS leukemia is usually easily confirmed by the identification of leukemic blasts on cytocentrifuge preparations of cerebrospinal fluid (CSF) after lumbar puncture. Relapse of LM carries a poor prognosis with a median survival of 6 months. Various treatment options include intrathecal chemotherapy (IT), systemic chemotherapy, and cranial radiation in patients. Conclusion: Acute leukemia can present with diverse CNS manifestations. All patients with a suspected CNS dysfunction should be promptly evaluated with a lumbar puncture to diagnose and hence avoid the dreaded complications of LM. References: 1) Dawson DM, Rosenthal DS, Moloney WC. Neurological complications of acute leukemia in adults: changing rate. Ann Int Med. 1973: 79(4); 541-544. 2) Thomas, Xavier; Le, Quoc-Hung. Central nervous system involvement in adult lymphoblastic leukemia. Hematology 2008:13(5):293-302.
Introduction: Simulation based medical education (SBME) is a key component of Advanced Cardiac Life Support (ACLS) training. Delivering effective feedback efficiently is critical in SBME. There is ...
