Oncology Case Challenge: A Retired Man With Left Upper Quadrant Pain, Leukocytosis

Kevin Zablonski; Jerry Wong, MD, PhD; Francisco J. Hernandez-Ilizaliturri, MD

Disclosures

May 04, 2022

Because of this patient's immunocompromised state, it was also necessary to rule out multiple potential infectious causes of brain lesions. This included analysis of the CSF for Nocardia, Toxoplasma, Cryptococcus, Cytomegalovirus, human polyomavirus 2, adenovirus, enterovirus, herpes simplex virus 1 and 2, and human herpes virus 6, which all have the ability to cause various neurologic deficits with associated changes on MRI. The tests were negative for these infectious agents.

Once the possibility of CNS involvement became evident in this case, the treatment regimen was altered to ensure adequate penetration of the blood-brain barrier while avoiding toxicity. For instance, ibrutinib, although shown to be effective in the treatment of HCL and HCL-v,[31] was avoided because of its potential to worsen the intracranial bleeding that was initially detected on MRI.[32] In addition, lenalidomide was considered because of its moderate penetration of the blood-brain barrier[33]; however, its use was not authorized by the patient's insurance company. Because lenalidomide and more targeted therapy were not approved, the patient was treated with bendamustine, rituximab, and intrathecal chemotherapy.

He was discharged after symptomatic improvement but was readmitted 12 days later with grade 3 mucositis and febrile neutropenia. A bone marrow biopsy showed hypocellular marrow (10%), with predominantly atypical lymphoid cells (90% involvement). Owing to the patient's deteriorating CNS status and his inability to take oral targeted agents, he was transitioned to hospice care.

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