Newsletter Lotus Oct 2022 Vol 11 issue 1
Respected friends and seniors,
We are hopefully all “Demasked” and enjoying our new found freedom! We are all excited to the new conference season where old friends meet up and catch up on lost time. We have all learnt to spend more time with family and friends and I hope we all continue the same without compromising on our patient care.
Case 1:
47 year old male who worked in food industry in Pune was diagnosed with Primary central nervous system (CNS) High grade B cell Non Hodgkin’s Lymphoma in April 2021 at Bombay hospital. He came to Lotus hospital post his surgery for his further treatment. He had neurological signs post his recent surgery with memory loss but no motor symptoms.
He had no systemic disease on his PET CT scan and his bone marrow was not involved. We started him on specific chemotherapy for his high grade lymphoma as the chemotherapy agents need to cross the blood brain barrier. We use chemotherapy drugs (cytarabine and methotrexate ) at “humongous doses! For eg.methotrexate which is routinely used in rheumatological and dermatological disorders at a dose of maximum may be 30-40 mg per week, is given at a dose of 5-8 gm per metre square (i.e 7-10 grams!!). We give leucovorin drug as a rescue to minimise systemic complications. We also used new drugs like Thiotepa.
He received 4 chemotherapy cycles and he was in complete remission on PET CT scan. He was very happy and continued his much-loved job in Pune. He was a fit person with regular cycling and swimming.
8 months later he developed headache and subsequent MRI brain showed a relapse of his disease. This is the most difficult situation to face for the treating doctor and the family.
The options we have when a serious cancer relapses:
- What are the chances of success after further chemotherapy/ radiotherapy?
- The need for bone marrow transplantation and its success?
- What if I don’t take any treatment (palliative therapy)?
- In our country, alternative therapy for cancers (after reading newspaper advtg and whatsup messages!)
My patient and his family were extremely well informed and after much discussions and opinions we decided on further chemotherapy followed by Autologous bone marrow transplantation (this type of transplant entails using our own stem cells as a source of transplant)
We used different chemotherapy agents this time to reduce the CNS tumour and then went ahead with stem cell collection. In this procedure we give the patient 4 days of growth factors (G CSF) to “bring” the stem cells from the bone marrow into the peripheral blood and then harvest the stem cells as (we do platelet collection) on an apheresis machine.
He underwent the transplant and then developed fever on 8 th day when his WBC were only 200! (yes 200!). This is the most crucial phase of the transplant. Unfortunately, his fever persisted and he developed sepsis and succumbed on 13 th day of his transplantation. The most important cause of mortality and morbidity in chemotherapy (for blood cancers) and bone marrow transplantation is sepsis due to MDR bacteria.
Cause of death: Carbapenem resistant Enterococci.
Take home messages:
- We are facing serious problems with multi drug resistant bacteria.
- Routine stool cultures from patients pre transplantation and chemotherapy show multi drug resistant bacteria!
- I think we discuss a lot and still give antibiotics where they are not indicated.
- We should strictly avoid antibiotics in viral fever.
- We should avoid MONOCEF in confirmed Dengue infection!
I know it is a pandora’s box and we can blame the system, the rampant use of antibiotics in poultry and animal husbandry. There may be medical stores selling antibiotics and major pharma companies will show “strong growth and finances’ in their quarterly results and the shares will “zoom” but I think we need to do what we can at our end to stop the rise of “super bugs”
My patient was a chef to our late prime minister shri Atal Bihari Vajpayeeji and was utterly missed by his family and his company where he was the most respected and the society lost a gem of a person.
Let us stop use of unnecessary antibiotics.
