A 63-year-old man with metastatic lung adenocarcinoma presented with biopsy confirmed toxic epidermal necrolysis (TEN). Symptoms commenced following 3 cycles of carboplatin, pemetrexed and pembrolizumab, with the first cycle given ~9.5 weeks prior to presentation. The patient was managed with immunosuppressive therapy including high dose methylprednisolone, cyclosporine, intravenous immunoglobulin, antibiotics and optimal skin care, and achieved excellent recovery of the skin lesions with minimal sequelae. This rare occurrence of pembrolizumab-induced TEN has only been reported previously in a few cases with limited evidence on management. Given the increasing use of immune checkpoint inhibitors and the long half-life of these agents, our case highlights the importance of recognizing this complication and of a multidisciplinary approach to management.
188 Background: Discussing an oncology patient’s ceiling of care in the emergency room (ER) is a high-stakes and time-pressured challenge. Discussions and consensus for ceilings are warranted when patients are acutely unwell with sepsis. We explored whether daily oral morphine equivalent (OME) was predictive of outcome and could therefore assist in ceiling of care decision making or advanced resuscitation planning (ARP). Methods: Oncology patients presenting with infection or sepsis to a quaternary hospital ER between October 2008 and April 2011 were included. Hospital electronic databases and medical records were manually reviewed to extract data on patient demographics, OME at time of presentation to ER, illness severity (SOFA scores), whether patients had a pre-existing formalised ARP vs acute ARP documented within the ER and 90-day mortality from ER presentation. Descriptive statistics were reported. Results: A total of 91 patients were identified with median age 64 years, 60% were male, 62% were undergoing palliative-intent treatment and 70% were receiving first-line chemotherapy. There were 54 patients taking no analgesia (OME 0) and 37 patients with an OME > 0. Of the 37 patients with OME > 0, 6 patients (16.2%) had an ARP documented in the ER. A further 14 patients with OME > 0 had an ARP documented at some point during their admission. The median total SOFA scores for patients with OME > 0 was 3 and OME of 0 was also 3. The 90- day mortality from ER presentation was higher for patients with an OME > 0 compared to those with an OME of 0 (Chi-square = 5.02, p = 0.03). There were 15/37 patients (40.5%) with an OME > 0 who were deceased within 90 days compared with 10/54 patients (18.5%) with an OME of 0. Conclusions: Patients with higher OME use at ER presentation had poorer outcomes and this may be useful to guide clinicians in ceilings of care decisions. Daily OME should signal a need for timely, formalised advanced care planning with patients and their treating oncologists.
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