Antineoplastics

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

In a case series 3 patients (one woman and two men) aged 33−72 years, were described, who developed COVID-19 infection, Staphylococcus epidermidis bacteraemia, complicated urinary tract infection (UTI) or influenza pneumonia during treatment with methylprednisolone, carboplatin, cytarabine, ifosfamide, paclitaxel, pembrolizumab, ipilimumab or rituximab for stage III squamous cell carcinoma of lung, relapsed diffuse large B-cell lymphoma or relapsed acute myeloid leukaemia [not all routes, dosages and durations of treatments to reactions onsets stated].

Case 1: A 65-year-old woman, who had medical history of radiation esophagitis anaemia, stage III squamous cell carcinoma of the right lung, grade 3 pneumonitis and pseudomonas pneumonia was hospitalised due to fever, shortness of breath, and fatigue. She had been receiving piperacillin/tazobactam for pneumonitis, carboplatin, ipilimumab and paclitaxel for stage III squamous cell carcinoma. Thereafter, pembrolizumab was added to the therapy. On admission, investigations revealed BP of 147/77mm Hg, pulse of 88 beats/minute, respiratory rate 20 breaths/minute, body temperature of 97.4°F. CT thorax revealed cavitary lesions in the right lobe with draining fistula and multifocal ground-glass opacities suggestive of nonspecific pneumonia. Upon admission, her antibacterial therapy was escalated to meropenem. Micafungin and IV methylprednisolone 60mg were also added to the therapy. Thereafter, her symptoms improved slowly. She had been in contact with her COVID-19 infected husband. She was moved to isolation ward. She tested positive for SARS-CoV-2 infection on RT-PCR testing. Thus, COVID-19 infection associated with carboplatin, paclitaxel, ipilimumab, pembrolizumab and methylprednisolone and was considered. Her therapy with chemotherapy was switched to off-label prednisone 50mg. It was gradually tapered to 10mg every 4th day. She was discharged without new onset of fever, nausea, pain and baseline respiratory symptoms. She had been prescribed piperacillin/tazobactam and oral prednisone. At follow-up, she was well without recurrence of fever and dyspnoea. Eventually, she resumed her chemotherapy.

Case 2: A 72-year-old man, who had medical history of benign prostatic hypertrophy, sarcoidosis, pulmonary embolism, relapsed diffuse large B-cell lymphoma with CNS involvement, neurosarcoidosis was previously hospitalised due to bacteraemia, neutropenic fever, post-obstructive pneumonia and COVID-19. He had been receiving R-ICE regimen including rituximab, ifosfamide, carboplatin and etoposide [etoposide phosphate]. Two weeks after completion of the chemotherapy, he tested positive for SARS-CoV-2 infection on RT-PCR testing. It was considered to be associated with rituximab, ifosfamide, carboplatin and etoposide. He was discharged with off-label hydroxychloroquine and azithromycin for COVID-19; vancomycin and cefepime for bacteraemia. After 2 days, he presented due to chronic hypoxic respiratory failure, weakness and increased oxygen requirements from 2L nasal cannula. On admission, investigations revealed BP of 91/62 mm Hg, pulse of 81 beats/minute, body temperature of 36.6°C and respiratory rate of 11 breaths/minute. Laboratory workup revealed elevated WBCs, ferritin and CRP. He also had dyspnea and hypoxia along with increased secretions and cough resulted in mucosal plugging. CT of thorax revealed obstruction from endobronchial lesions in the left upper and lower lobe of the left lung. Thereafter, he received off-label hydroxychloroquine 200mg and azithromycin 250mg, in addition to supplemental oxygen. He continued receiving vancomycin for Staphylococcus epidermidis bacteremia associated with the chemotherapy received. A week later, his condition improved and discharged with instructions of self isolation.

Case 3: A 33-year-old man, who had relapsed acute myeloid leukaemia and had been receiving high-dose cytarabine. A month after the last administration of cytarabine, he was hospitalised due to influenza pneumonia, complicated UTI and presented fever. He tested positive for SARS-Cov-2 infection on RT-PCR testing. Thus, COVID-19 infection, influenzal pneumonia and complicated UTI associated with cytarabine was considered. On admission, investigations revealed BP of 129/81mm Hg, heart rate of 94 beats/minute, respiratory rate of 17 breaths/minute, body temperature of 37.2°C, pulse of 94 beats/minute. Laboratory workup revealed elevated ferritin and D dimer. Three days later, he was discharged with improvement. A week later, he presented due to persistent fatigue, fever and intermittent shortness of breath. He also had He has had a productive cough of clear sputum and central chest discomfort. Investigations revealed at this time, body temperature of 38.1°C, blood pressure of 110/69mm Hg, heart rate of 103 beats/minute, pulse of 103 beats/minute and oxygen saturation of 94%. Scans revealed worsening left basilar consolidation with suspicion of pneumonia. Thereafter, he started receiving off-label IV dexamethasone 10mg, cefepime 2000mg and oral azithromycin 250mg every 24h, in addition to convalescent anti SARS-CoV-2 plasma [convalescent plasma]. Additionally, he received cotrimoxazole. Thereafter, his condition improved significantly. Eventually, he was discharged with instructions of self isolation.