A 76-year-old woman from a tuberculosis (TB) endemic region with chronic myelomonocytic leukemia (CMML) on Azacitidine presented with a non-productive cough. A CT scan of the chest revealed a lobulated opacity in the right upper lobe and antibiotic therapy was initiated for a potential bacterial pneumonia. However, a high suspicion for pulmonary TB remained given her nation of origin, immunosuppression, and imaging findings. Three sputum and bronchoalveolar lavage (BAL) acid-fast bacilli (AFB) smears with PCR testing for Mycobacterium tuberculosis were negative, as were examinations for other potential fungal or bacterial etiologies of the patient's symptoms and imaging findings. While awaiting final TB culture results from BAL, her CMML underwent a transformation to acute myeloid leukemia (AML). Given the urgent need for initiation of chemotherapy, empiric treatment for TB was commenced while awaiting the final TB culture. Within 48-hours of initiating therapy for TB, the patient's fevers subsided. One week after discharge our team was notified of a positive M. tuberculosis culture from BAL. We suspect that our patient had a latent TB infection which reactivated due to her CMML. This case highlights the importance of maintaining a high clinical suspicion for TB in high-risk patients, even in the case of initially negative laboratory examinations. Further, it demonstrates the importance of screening and treating latent TB in patients with leukemias.

Methotrexate is a versatile antineoplastic and immunosuppressive agent. We report a case of a young adult on the Cancer and Leukaemia Group B 10403 treatment protocol for B-cell acute lymphoblastic leukaemia. She has previously completed the induction and consolidation phases with good tolerance then started on Capizzi methotrexate during the interim maintenance phase. Few days after receiving one intermediate dose of methotrexate, she developed severe multiorgan toxicities including pancytopaenia and several dermatologic toxicities. The patient underwent extensive diagnostic workup, with all results negative, pointing eventually towards severe methotrexate toxicity. This case highlights the broad spectrum of toxicities that can occur even with low doses of methotrexate. Capizzi methotrexate therapy implies no leucovorin therapy, hence putting patients at risk for multiorgan toxicity. Our experience reinforces the importance of close monitoring for patients receiving methotrexate, regardless of dose, and the prompt administration of high-dose leucovorin once toxicity suspected.

Context Corticosteroids, specifically dexamethasone, have become the mainstay of treatment for moderate to severe COVID-19. Although the RECOVERY trial did not report adverse effects of corticosteroids, the METCOVID (Methylprednisolone as Adjunctive Therapy for Patients Hospitalized with COVID-19) study reported a higher blood glucose level in patients receiving methylprednisolone. Objectives This study aims to analyze the association between corticosteroids and COVID-19–related outcomes in patients admitted to the medical ICU (MICU) for COVID-19 pneumonia. Methods This is an observational study of 141 patients admitted to the MICU between March 18 and June 7, 2020. Data on demographics, laboratory and imaging studies, and clinical course were obtained, including data on corticosteroid use. Bivariate analyses and logistic regression were performed between patient characteristics and mortality and successful extubation. Results Of the 141 patients, 86 required mechanical ventilation, 50 received steroids, and 71 died. Regarding demographics, patients had a median age of 58 (interquartile range [IQR] 48, 65), Hispanic (57.4%, n=81), and non-Hispanic Black (37.5%, n=53). The most prevalent comorbidities were hypertension (49.6%, n=70) and diabetes (48.2%, n=68). Lower blood glucose levels on admission (125.5 vs. 148 mg/dL, p=0.025) and lower peak blood glucose levels on corticosteroids (215.5 vs. 361 mg/dL, p=0.0021) were associated with lower prevalence of mortality. Patients who were successfully extubated had a lower admission blood glucose (126.5 vs. 149 mg/dL, p=0.0074) and lower peak blood glucose on corticosteroids (217 vs. 361 mg/dL, p=0.0023). Conclusions Lower blood glucose on admission and lower maximum blood glucose on corticosteroids were associated with lower odds of mortality and successful extubation, regardless of preexisting diabetes. Hyperglycemia may be negating any potential benefit of corticosteroid therapy. These findings suggest that glucose control could be a parameter that impacts the outcome of patients receiving corticosteroids for COVID-19 pneumonia.

Reactivation of latent Tuberculosis (TB) occurs in high risk patients like HIV, solid transplantation and hematologic malignancies. We present a case of active TB in a patient with Chronic Myelomonocytic leukemia (CMML) on chemotherapy who presented as community acquired pneumonia (CAP) and was later proven to be TB. CASE PRESENTATION: Patient was a 76 years old lady who immigrated from the Philippines and has a 4-month history of CMML on Azacitidine (5-AZC). She complained of 10 days of fever and pleuritic chest pain. Her physical exam was unremarkable and laboratory results showed leukocytosis. CT scan showed a new right upper lobe opacity when compared to her prior CT from 4 months earlier. She was promptly started on antibiotics for CAP. Despite 3 days of antibiotic therapy, she continued to be febrile. Due to a lack of response to antibiotics, location of the opacities and country of origin, pulmonary TB was considered and 3 samples of sputum were sent. AFB smears with Nucleic-acid amplification testing (NAAT-PCR) for M. tuberculosis came back negative. Given unrevealing work, including negative workup for fungal infections, she underwent a bronchoscopy. AFB smear from the broncho alveolar lavage was also negative. She remained hospitalized for persistent fevers when her CMML underwent transformation to acute myeloid leukaemia (AML). Given the need for initiation of AML specific therapy, a decision was made to begin empiric treatment for TB while awaiting final culture results. 48 hours after beginning empiric therapy with Rifamycin, Isoniazid, Pyrazinamide and Ethambutol, her fevers subsided and she was discharged with Direct Observation Treatment (DOT) visits. A week later, sputum cultures came back positive for Mycobacterium tuberculosis. The patient reported overall symptomatic improvement and she remains on therapy at this time. DISCUSSION: We suspect that our patient from the TB-endemic Philippines had a latent TB infection which was subsequently reactivated. We propose the reactivation was primarily the result of her CMML, classified as an overlap of Myelodysplastic syndromes (MDS) and Myeloproliferative neoplasms (MPN). MDS and MPN were found to have the greatest risk for TB in comparison to other malignancies [1]. This increased susceptibility is either a direct consequence of immunosuppression from the malignancy, secondary to therapy, or both. [2] 5-AZC could increase the risk for reactivation of TB by loss of T-cell populations. [3] CONCLUSIONS: This case highlights the importance of high clinical suspicion for TB in high risk groups even in the setting of negative AFB PCR (95% sensitivity), and reinforces the importance of clinical judgement in cases where confirmatory results may take prolonged periods of time. Also, demonstrates the importance of screening and treatment of latent TB in patients with leukemia.

To our knowledge there have been no reported cases of a patient presenting with diabetic ketoalkalosis due to an ACTH secreting tumor. We are reporting a case of a well known disease, diabetic ketoacidosis, presenting in a novel way from a rare paraneoplastic phenomena.

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Objective: Dermatomyositis (DM) and polymyositis (PM) are systemic autoimmune diseases that have been associated with high in-hospital mortality (IHM). The aim of this study was to use the National Inpatient Sample (NIS), a large US population database, to determine the reasons for hospitalization and IHM in patients with DM and PM.Methods: We conducted a medical records review of adult DM/PM hospitalizations in 2016 and 2017 in acute care hospitals across the United States using the NIS. The reasons for IHM and reasons for hospitalization were divided into 19 broad categories based on their principal International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis.Results: A total of 27,140 hospitalizations carried either a principal or secondary ICD-10 code for DM or PM. The main reasons for hospitalization were rheumatologic (22%, n = 6085), cardiovascular (15%, n = 3945), infectious (13%, n = 3515), respiratory (12%, n = 3170), and gastrointestinal, (8%, n = 2150). A total of 3.5% of all patients experienced IHM. Infectious (34%, n = 325), respiratory (23%, n = 215), and cardiovascular (15%, n = 140) diagnoses were the most common reasons for IHM. Sepsis ICD-10 A41.9 was the most frequent specific principal diagnosis for both hospitalizations and IHM.Conclusions: Our analysis demonstrated that in the NIS the most common reasons for hospitalization in patients with DM/PM were rheumatologic diagnoses. However, IHM in these patients was most frequently from infectious diagnoses, highlighting the need for increased attention to infectious complications in these patients.