New-Onset Diabetic Ketoacidosis Secondary to Nivolumab Therapy in a Patient with Primary Central Nervous System Lymphoma

2021 ◽  
pp. 40-43
Author(s):  
Christine Feng ◽  
Pavel Kibrik ◽  
Christian Castañeda ◽  
Gurdeep Singh
Keyword(s):  
Diabetes Mellitus ◽  
Central Nervous System ◽  
Nervous System ◽  
Diabetic Ketoacidosis ◽  
Checkpoint Inhibitors ◽  
Central Nervous System Lymphoma ◽  
Anion Gap ◽  
Prior History ◽  
Life Threatening ◽  
History Of

Introduction: Inhibitors of programmed cell death receptor (PD-1) and its ligand (PD-L1), such as nivolumab and pembrolizumab, confer anti-autoimmune activities and are therefore approved for anti-cancer therapy. Their mode of action removes autoimmunity checkpoints, thus increasing the risk of immune-related adverse events. Case Presentation: This report describes a clinical case of life-threatening diabetic ketoacidosis (DKA) in a patient after long-term nivolumab administration to treat primary central nervous system lymphoma (PCNSL). The patient presented to the emergency department (ED) with symptoms of fatigue, along with nausea and vomiting for two days; laboratory testing revealed significant hyperglycemia (glucose 673 mg/dL), elevated anion gap (>27), metabolic acidosis, ketonemia, glucosuria and ketonuria, findings of which were consistent with DKA. Given no personal history of diabetes mellitus or other autoimmune conditions and additional tests ruling out alternative causes, the patient was suspected of having newly-onset DKA secondary to nivolumab treatment. Management & Outcome: The patient was treated with fluids, electrolytes replenishments and insulin drip, which closed the anion gap and normalized electrolytes. She was transitioned to subcutaneous insulin. The patient recovered well and was discharged on Metformin and longacting insulin, with close follow-up with endocrinology and oncology. Discussion: Autoimmune endocrinopathies induced by checkpoint inhibitors for cancer treatment have been reported in the past. Newly-onset hyperglycemia and DKA are common autoimmunemediated side effects of checkpoint inhibitor uses in patients without prior history of diabetes mellitus. Clinicians should be aware to prevent this potentially life-threatening condition.

Venous Thromboembolism Prophylaxis with Low-Molecular-Weight Heparin in Primary Central Nervous System Lymphoma

2020 ◽  
pp. 1-6
Author(s):  
Stav Gazal ◽  
Eyal Lebel ◽  
Yosef Kalish ◽  
Chen Makranz ◽  
Moshe E. Gatt ◽  
...  
Keyword(s):  
Molecular Weight ◽  
Central Nervous System ◽  
Nervous System ◽  
Venous Thromboembolism ◽  
Low Molecular Weight Heparin ◽  
Bleeding Event ◽  
Central Nervous System Lymphoma ◽  
B Cell Lymphoma ◽  
Low Molecular Weight ◽  
History Of

<b><i>Background:</i></b> Venous thromboembolism (VTE) is a frequent, potentially lethal complication in individuals with cancer. Patients with brain tumors are at particularly high risk for VTE. Primary central nervous system lymphoma (PCNSL) is a rare subtype of diffuse large B cell lymphoma, involving the craniospinal axis. The incidence of VTE in patients with PCNSL was reported as very high, occurring mostly in the early period of therapy. <b><i>Objectives:</i></b> We aimed to evaluate the efficacy and safety of prophylactic low-molecular-weight heparin (LMWH) throughout the treatment of PCNSL. <b><i>Patients:</i></b> All patients &#x3e;18 years of age diagnosed and treated for PCNSL at our institution in 2005–2017 were included. <b><i>Results:</i></b> There were 44 patients; mean age at diagnosis was 61.5 years. Three patients (6.8%) had a personal history of thrombosis, 11 (25%) had a history of diabetes or smoking, and 32 (72%) had an Eastern Cooperative Oncology Group performance status of 0–1 at diagnosis. During treatment with LMWH, no VTE events were recorded; 2 (4.5%) patients experienced a minor bleeding event and 1 (2.3%) a major bleeding event. <b><i>Conclusions:</i></b> Among our 44 patients with PCNSL treated with prophylactic LMWH, no VTE events were recorded, and only 1 (asymptomatic) intracranial bleed was recorded. Within the limitations of a retrospective nonrandomized study, our findings suggest that VTE prophylaxis may be beneficial for individuals with PCNSL.

scholarly journals Primary peripheral T-cell central nervous system lymphoma

2021 ◽  
Vol 12 ◽  
pp. 465
Author(s):  
Cylaina E. Bird ◽  
Jeffrey I. Traylor ◽  
Jenna Thomas ◽  
James P. Caruso ◽  
Benjamin Kafka ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
T Cell ◽  
Sjögren’S Syndrome ◽  
Sjögren's Syndrome ◽  
Central Nervous System Lymphoma ◽  
Sjogren’S Syndrome ◽  
Sjogren's Syndrome ◽  
History Of ◽  
Sjögren‘S Syndrome

Background: Primary peripheral T-cell central nervous system lymphoma (PCNSL) is a rare, aggressive tumor that arises in the craniospinal axis and has an increased risk in individuals who are immunocompromised. This lesion often mimics other benign and malignant processes on radiographic imaging, leading to misdiagnosis and delays in treatment. We present a case of a patient with a history of Sjögren’s syndrome and progressive neurologic symptoms who underwent craniotomy for diagnosis. Case Description: A 61-year-old woman with a history of Sjögren’s syndrome, progressive aphasia, left facial droop, and right-sided paresthesias for 4 months presented for evaluation and management. An enhancing, infiltrative lesion in the left frontal lobe with underlying vasogenic edema was appreciated and suggestive of a primary or metastatic neoplasm. The patient underwent an open biopsy for further evaluation of the lesion. Extensive histopathologic evaluation revealed a diagnosis of T-cell PCNSL. The patient was started on induction methotrexate and temozolomide followed by consolidative radiotherapy. Conclusion: Autoimmune conditions are a risk factor for T-cell PCNSL development. T-cell PCNSL has radiographic and gross histologic features that are consistent with a broad differential, including gliomas and inflammatory processes. Prompt diagnosis and extensive histopathological evaluation is essential to ensure appropriate treatment.

scholarly journals Low Molecular Weight Heparin (LMWH) for Venous Thromboembolism (VTE) Prophylaxis in Patients with Primary Central Nervous System Lymphoma (PCNSL)

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 2993-2993
Author(s):  
Deborah Rund ◽  
Stav Gazal ◽  
Yosef Kalish ◽  
Chen Makranz ◽  
Neta Goldschmidt
Keyword(s):  
Molecular Weight ◽  
Central Nervous System ◽  
Nervous System ◽  
Venous Thromboembolism ◽  
Low Molecular Weight Heparin ◽  
Medical Center ◽  
Bleeding Event ◽  
Central Nervous System Lymphoma ◽  
Low Molecular Weight ◽  
History Of

Abstract Introduction: Venous thromboembolism (VTE) is a frequent, potentially lethal, complication in patients with cancer. Patients with brain tumors are at a particularly high risk for VTE. Primary central nervous system lymphoma (PCNSL) is a rare subtype of diffuse large B-cell lymphoma, involving the cranio-spinal axis. The incidence of VTE in patients with PCNSL is as high as 30-60% in various series, occurring mostly in the early period of therapy. Due to this high incidence, the policy in our medical center since the year 2005, is to treat with prophylactic low molecular weight heparin (LMWH) from the time of PCNSL diagnosis until the end of treatment. We aimed to evaluate the incidence of VTE in patients with PCNSL treated with prophylactic LMWH. Material and methods: All patients ≥18 years who were diagnosed and treated for PCNSL in Hadassah-Hebrew University Medical Center between the years 2005-2017 were included in the study. We retrospectively reviewed their medical records for demographic details and initial disease characteristics (age at diagnosis, sex, performance status, laboratory results such as LDH, cerebrospinal fluid content and location of the growth), for details of risk factors for VTE such as diabetes, smoking or heart failure, and for personal or familial history of thrombosis. Therapeutic details including chemotherapy protocol, response to treatment and supportive care were compiled. Specifically we noted if prophylactic LMWH was given, if any complications developed due to the LMWH treatment and whether a VTE event occurred. Results: Forty four patients were included in the study. Mean age at diagnosis was 60.2 years and there were 27 (61%) females. Three (6.8%) patients had a personal history of thrombosis and 13 (29%) had a history of diabetes or smoking. Thirty two (72%) had an ECOG performance study of 0-1 at diagnosis and seven (16%) had leptomeningeal involvement. Forty one (93%) of patients were treated with a systemic high dose methotrexate (HDMTX) based protocol (mean of 7.6 courses of HDMTX per patient) and thirty two (73%) patients were treated with systemic rituximab. All 44 patients were treated with prophylactic LMWH, mostly at a dose of 40 mg per day (41 patients, 93%). Of the 44 patients, five (11%) discontinued treatment; 2 due to side effects (abnormal liver function tests and subdural hematoma (SDH)) and 3 for an unknown reason. Three (7%) patients had a minor bleeding event (gum, conjunctival, Ommaya reservoir catheter tract). One patient (2.3%) had a major bleeding event (SDH) while on LMWH treatment which was found on routine MRI imaging of the brain as he was asymptomatic. No VTE events (0%) were recorded in patients treated with LMWH. Two patients had a VTE, however both patients were off LMWH treatment at the time of VTE (one stopped LMWH, the other was diagnosed with VTE concurrently with the diagnosis of PCNSL). Conclusions: In our group of 44 PCNSL patients, prophylactic use of LMWH was highly effective, with no VTE events. Two cases of VTE occurred in our patient group, both occurred while the patients were off LMWH treatment. Only one, asymptomatic, intracranial bleed was recorded, indicating the relative safety of this treatment in PCNSL patients. Further prospective studies should be done to support the routine use of this prophylactic strategy. Disclosures No relevant conflicts of interest to declare.

scholarly journals Creutzfeldt–Jakob Disease with a Five-Year Clinical Course, Multicentric Cerebellar Prion Plaques and Prior History of Biopsy-Proven Primary Angiitis of the Central Nervous System: A Case for Iatrogenic Exposure?

Viruses ◽  
2020 ◽  
Vol 12 (12) ◽  
pp. 1411
Author(s):  
Kristina Jeon ◽  
Jeffrey T. Joseph ◽  
Gerard H. Jansen ◽  
Anne Peterson ◽  
J. David Knox ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Parietal Lobe ◽  
Clinical Course ◽  
Prior History ◽  
System A ◽  
Primary Angiitis ◽  
History Of ◽  
Jakob Disease ◽  
The Central Nervous System

Creutzfeldt–Jakob disease (CJD) is a rapidly progressive neurodegenerative disease that can arise spontaneously, genetically, or be acquired through iatrogenic exposure. Most patients die within a year of symptom onset. It is rare, affecting 1–2 per million per year, and the majority of cases are sporadic. Primary angiitis of the central nervous system (PACNS) is also rare, affecting 2.4 per million per year. We present a case of an unusually long clinical course of CJD, almost five years, which began with symptoms of apraxia. The patient had biopsy-proven PACNS 16 years prior to clinical presentation, and the site of biopsy was the left parietal lobe. Autopsy revealed multicentric prion plaques in the cerebellum, in the setting of normal genetic testing. The presence of plaques in the cerebellum, and prior neurosurgery, raises the possibility of iatrogenic exposure. We present the details of this case, including pathology from the original biopsy and final autopsy, as well as a review of relevant cases in the literature.

Euglycemic Diabetic Ketoacidosis in a Diabetic Patient Treated with SGLT2 Inhibitor

2021 ◽  
Vol 6 (1) ◽  
Author(s):  
Lavrynenko O ◽  
◽  
Santos H ◽  
Garza A ◽  
Qazi R ◽  
...  
Keyword(s):  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Glucose Transporter ◽  
Sglt2 Inhibitor ◽  
Anion Gap ◽  
Laboratory Evaluation ◽  
Intravenous Insulin ◽  
Glucose Transporter 2 ◽  
Life Threatening ◽  
History Of

Diabetic Ketoacidosis (DKA) is a life - threatening complication and must be diagnosed and treated promptly and aggressively. The classic triad of DKA is hyperglycemia (Blood Glucose (BG) >250mg/dl; anion gap metabolic acidosis (pH <7.30 and bicarbonate <18mEq/L); and ketonemia. With Food and Drug Administration (FDA) approval of the sodium - glucose transporter 2 inhibitors (SGLT2i), DKA can occur with BG levels below 200mg/dl and has been defined as Euglycemic DKA (EuDKA). Due to the absence of hyperglycemia, the diagnosis of EuDKA is challenging and often delayed. This 60-year-old diabetic male, treated with Empagliflozin and pioglitazone, presented with diarrhea and abdominal pain, which started 20 days ago. He was admitted with dehydration and diagnosis of colitis. On admission laboratory evaluation revealed metabolic acidosis with elevated anion gap of 18mEq/L, bicarbonate of 19mEq/L, and BG of 146mg/dL. There was no history of ingestion of alcohol, salicylates, methanol, ethylene glycol and nothing to suggest lactic acidosis. The plasma creatinine was 0.79mg/dl. On the following day, he developed an increase in the anion gap to 22mEq/L and further decrease in bicarbonate to 13mEq/L, and serum ketones were detected. The patient was treated for EuDKA in ICU with intravenous insulin, dextrose (to prevent hypoglycemia), and normal saline with resolution of his symptoms and EuDKA in 3 days. With the widespread use of SGLT2i, physicians need to have a high suspicion of EuDKA in patients who present with an unexplained anion gap acidosis without or only modest elevation in BG concentration.

Presentation of mixed diabetic ketoacidosis and metabolic acidosis due to ileal neobladder reconstruction

2021 ◽  
Vol 14 (2) ◽  
pp. e223668
Author(s):  
Dileep Kumar ◽  
Muhammad Zubair Nasim ◽  
Bilal Ahmad Shoukat ◽  
Syed Shabahat Ali Shah
Keyword(s):  
Diabetes Mellitus ◽  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Plasma Glucose ◽  
Blood Gas Analysis ◽  
Gas Analysis ◽  
Anion Gap ◽  
Metabolic Complications ◽  
Ileal Neobladder ◽  
History Of

Diabetic ketoacidosis (DKA) is one of the most serious acute metabolic complications of diabetes mellitus. It is characterised by the biochemical triad of hyperglycaemia, ketonemia/ketonuria, and an increased anion gap metabolic acidosis. In this case, a 40-year-old male patient presented to the emergency department, with vomiting, nausea, polydipsia, polyuria and weight loss. He was found to have an elevated plasma glucose, despite having no known history of diabetes mellitus. His medical history was significant for spina bifida and ileal neobladder reconstruction. The plasma glucose level was 38 mmol/L. Blood gas analysis showed normal anion gap metabolic acidosis with high chloride and low bicarbonate. His plasma ketone level was 4.5 mmol/L. No significant reason for hyperchloraemia was identified. On initiation of DKA regimen, his condition improved and serum ketones normalised. Due to persistent hyperchloraemic metabolic acidosis, bicarbonate infusion was administered and his metabolic acidosis resolved.

scholarly journals A Case of Central Nervous System Lymphoma Manifesting as Multiple Patchy White Matter Lesions with a Past History of Tonsil Lymphoma

2012 ◽  
Vol 59 (1.2) ◽  
pp. 33-38
Author(s):  
SUSUMU KOBAYASHI ◽  
KEITA SAKURAI ◽  
MOTOKI TANIKAWA ◽  
YUSUKE NISHIKAWA ◽  
NORIYUKI MATSUKAWA ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
White Matter ◽  
Past History ◽  
Central Nervous System Lymphoma ◽  
White Matter Lesions ◽  
History Of

scholarly journals NCMP-06. METASTATIC CENTRAL NERVOUS SYSTEM DISEASE SECONDARY TO BURKITT LYMPHOMA IN A PATIENT WITH PRIOR HISTORY OF MELANOMA

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii124-ii124
Author(s):  
Uju Momah ◽  
Jennifer Brewer ◽  
Anthony Tran ◽  
David Shapiro
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Central Nervous System Disease ◽  
Burkitt’S Lymphoma ◽  
Adult Patients ◽  
Burkitt's Lymphoma ◽  
Prior History ◽  
System Disease ◽  
History Of ◽  
The Central Nervous System

Abstract Sporadic Burkitt’s Lymphoma accounts for only 1–2% of Non Hodgkin’s Lymphoma, and metastasizes to the central nervous system (CNS) is uncommon, occurring in about 13–17% of adult patients. 1 Melanoma is far more likely to metastasize to the CNS, occurring in about 37% of adult patients.2 Here we present the case of a 69 year old Gambian female with a prior medical history of plantar melanoma. She initially presented to her primary care provider with back pain and adenopathy, and was referred to surgical consultation for diagnosis and concern for recurrent melanoma. Her workup revealed metastatic Burkitt’s Lymphoma with disease in the abdomen, lungs and likely CNS involvement. This report chronicles her disease course and approach to management.

scholarly journals Emerging Landscape of Immunotherapy for Primary Central Nervous System Lymphoma

Cancers ◽  
2021 ◽  
Vol 13 (20) ◽  
pp. 5061
Author(s):  
Marion Alcantara ◽  
Jaime Fuentealba ◽  
Carole Soussain
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
B Cell ◽  
Checkpoint Inhibitors ◽  
Central Nervous System Lymphoma ◽  
B Cell Lymphoma ◽  
Medical Need ◽  
Germinal Center B Cell ◽  
Car T ◽  
Anti Cd20

Primary central nervous system lymphoma (PCNSL) is, mainly, a diffuse large B-cell lymphoma (DLBCL) with a non-germinal center B-cell (non-GCB) origin. It is associated with a poor prognosis and an unmet medical need. Immunotherapy has emerged as one of the most promising areas of research and is now part of the standard treatment for many solid and hematologic tumors. This new class of therapy generated great enthusiasm for the treatment of relapsed/refractory PCNSL. Here, we discuss the challenges of immunotherapy for PCNSL represented by the lymphoma cell itself and the specific immune brain microenvironment. We review the current clinical development from the anti-CD20 monoclonal antibody to CAR-T cells, as well as immune checkpoint inhibitors and targeted therapies with off-tumor effects on the brain microenvironment. Perspectives for improving the efficacy of immunotherapies and optimizing their therapeutic role in PCNSL are suggested.

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