cells including histiocytes, some of which contained cytoplasmic inclusions. Initial infectious workup was unremarkable. Ferritin was grossly elevated to >26,000 micrograms/L. Given patient’s lung biopsy findings, worsening clinical status, and progressive cytopenias, HLH was considered and worked up per HLH-94 guidelines. A bone marrow biopsy showed hypercellular marrow and erythrophagocytosis without underlying dysplasia. The IL-2 receptor was significantly elevated. H-score was calculated to be 284, which equates to >90% probability of hemophagocytic syndrome. This was deemed sufficient to begin treatment with Etoposide and Dexamethasone for HLH, and the
patient showed marked clinical improvement upon therapy initiation. Expanded workup for viral etiologies did reveal EBV positivity by PCR, which may have been the inciting factor. He will require further evaluation for malignancy. Discussion: The diagnosis of HLH remains challenging as patients initially present with non-specific findings, prompting clinicians to eliminate other differentials first. Timely diagnosis is of utmost importance due to HLH’s high mortality rate. This case exemplified the utility of HLH-94 guidelines in promptly diagnosing and initiating treatment in suspected HLH.
POSTER PRESENTATIONS – RESIDENTS
A RARE CASE OF FATAL DRUG INDUCED HEPATITIS SECONDARY TO IMMUNE CHECKPOINT INHIBITOR Jaahnavi Konidala MD, Natasha Santosh MD; Department of Medicine Willis-Knighton Medical Center, Shreveport, LA.
Introduction: Immunotherapy, including immune checkpoint inhibitors (ICPI), have presented new effective treatment modalities for various cancers. Durvalumab (PDL-1 inhibitor) is one such drug known to cause hepatitis in rare occasions managed successfully with corticosteroids or combination immunosuppression. In this report, we present a case of fatal grade 4 ICPI induced hepatitis failing monoclonal antibody therapy. Case: A 59-year-old female with hypertension, coronary artery disease, unresectable stage III non- small cell carcinoma without evidence of metastasis on PET scan, on durvalumab for 9 months, and a former smoker presented to oncology clinic with sudden onset worsening nausea and vomiting associated with diffuse abdominal pain radiating to the right shoulder and fatigue for 1 day. Examination was remarkable for generalized icterus without abdominal tenderness. An EKG showed no significant ST-T wave changes. Labs were significant for the ratio of ALT/ALP >5, an elevated PT/INR and an acute kidney injury. Infectious workup was negative. The serum acetaminophen level was normal. Autoimmune workup was negative. Ultrasound of the abdomen was negative for portal vein thrombosis. Durvalumab was determined to be the cause of her liver injury. The patient was treated with methylprednisolone 1mg/
kg with dramatic resolution of the derangements in her liver function tests. Her abnormal tests returned to baseline so she was discharged on oral prednisone. On follow up four days after discharge, labs showed recurrent elevation in liver function tests with a total bilirubin of 28 mg/dl. The patient was admitted, started on methylprednisolone, and required intubation for rapidly worsening mentation. Further immunosuppression was attempted with mycophenolate and then tocilizumab. Ultimately, she went on to develop hepatorenal syndrome requiring renal replacement therapy, multiorgan dysfunction and bleeding diathesis. She was not a suitable candidate for transplant due to malignancy and poor prognosis. The family opted for withdrawal of care in accordance with the patient’s wishes. Discussion: This is the first case ever reported with fatal grade 4 ICPI induced hepatitis despite use of monoclonal antibodies. Previous reports of ICPI hepatitis noted improvement with either corticosteroids or with combination of steroids and other immunosuppressants, rarely requiring monoclonal antibodies. With increasing use of immunotherapy, more such cases are likely to be reported. Early diagnosis and treatment of ICPI hepatitis is vital to improving patient outcomes.
14
Made with FlippingBook Digital Publishing Software