Introduction: The array of unintended effects of targeted oncological treatments is still being elucidated. Cognizance of these effects is important since they allow early identification and intervention. Methods: We report a case of progressive reduction in kidney function following the introduction of the oral second generation Anaplastic Lymphoma Kinase (ALK) Inhibitor: Alectinib for the treatment of metastatic non-small cell carcinoma of the lung (NSCLC). Kidney biopsy findings suggested that the predominant manifestation was acute tubular injury, which resolved with cessation of Alectinib therapy and did not recur with the introduction of the third generation ALK inhibitor Lorlatinib. Conclusions: This case report adds to the Onco-Nephrology literature in relation to the potential nephrotoxic effects of ALK inhibitors.
Question: A 55year-old Caucasian MAN presented to our emergency department with a 2-week history of exertional dyspnea, petechial lower limb rash on a background of night sweats, pyrexia, arthralgia, and a 12kg weight loss. He reported recent 7day history of selflimiting diarrhea. Medical history included lumbar disc prolapse, depression, and iron deficiency anemia investigated 9 months earlier. Investigations at that time included normal colonoscopy and suspected nonsteroidal anti-inflammatory drug-induced gastritis on gastroscopy. Medications on admission included escitalopram and dexketoprofen, in addition to iron and folate supplementation. The patient is a nonsmoker and employed as a security guard.The physical examination showed a bilateral lower limb petechial rash and indurated nodules. Laboratory investigations revealed a microcytic iron deficiency anemia (hemoglobin, 9.8 g/dL; mean corpuscular volume, 73 fL; iron 2.8 mg/dL; transferrin saturations, 6%; and ferritin, 117 ng/mL). Inflammatory markers were elevated (C-reactive protein, 76 mg/dL; and erythrocyte sedimentation rate, 54 mm/h). Renal, bone, and liver profiles were performed and minimally elevated gamma glutamyl transferase and hypoalbuminemia 33 g/L were noted. Vasculitic screen was nondiagnostic. A contrastenhanced computed tomography scan of the thorax, abdomen, and pelvis revealed abdominal lymphadenopathy (Figure A), which was subsequently biopsied with computed tomography guidance and dermatology review led to skin biopsy of lower limb petechial rash.The patient was referred to gastroenterology for investigation of iron deficiency anemia. Gastroscopy was grossly abnormal with diffusely inflamed and erythematous duodenal mucosa and reported friability and contact hemorrhage (Figure B). Urease testing for Helicobacter pylori was positive, and triple therapy for eradication commenced with esomeprazole, clarithromycin, and amoxicillin. Within 7 days, the patient's symptoms, fever, and rash had resolved.What is the unifying diagnosis? How was the diagnosis confirmed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
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