Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What treatment options do you consider if eosinophilia with end organ dysfunction persists with q8 week dosing of benralizumab and you can't obtain approval for q4 week dosing?
Depending on the degree of eosinophilia and end-organ dysfunction, if the patient is not already on oral steroids, they probably should be pending a new plan for a steroid-sparing agent. Is the diagnosis more consistent with HES or EGPA? Has the patient failed mepolizumab 300 mg? There is good data ...
How would you treat an elderly, transplant-ineligible patient with recurrent DLBCL?
There is no single standard of care in the treatment of transplant-ineligible relapsed or refractory DLBCL in the second line. Many regimens would be considered relevant considerations here, including rituximab, gemcitabine, and oxaliplatin; bendamustine and rituximab; rituximab and dose-adjusted EP...
In a patient with type I von Willebrand disease who is pregnant and at increased risk for preeclampsia, would you recommend treatment with aspirin?
Yes, and is tolerated well.
When would you initiate exchange transfusion in babesiosis and significant hemolysis?
There are no studies that answer this question. Some people have extrapolated from the use of exchange transfusions for severe malaria to consider using this treatment with babesiosis, another intraerythrocytic protozoan infection. Unfortunately, though there are some studies on malaria, the results...
How do you choose which BTK inhibitor to use in NHL?
At this point, I use very little ibrutinib. If I need CNS penetration, ibrutinib has a track record there. Otherwise, I have pivoted to acalabrutinib and zanubrutinib. I typically will pick by indication - acala for CLL and zanu for WM/MZL. In MCL or likely soon in CLL, I am not entirely sure how to...
Would you re-challenge a CLL patient, who had good response to Zanubrutinib but contracted cryptococcal pneumonia, with another BTK inhibitor?
Infections are part of the natural history of CLL. While cryptococcal meningitis is the uncommon one in CLL, it does occur when these patients are on steroids, have prior receipt of fludarabine, bendamustine, or other treatments which suppress the cellular immune system (in particular CD4+ T-cells)....
What parasites do you screen for in your workup of HES?
In my practice, if GI symptoms (particularly diarrhea), then culture for stool ova and parasites (broad screen). If there are no GI symptoms, then only screening for Strongyloides with a blood test for Strongyloides antibody. If there is a recent travel history or a patient immigrated from areas wi...
How would you manage a gastric MALT patient with anemia and peri-gastric and abdominal retrocaval nodal involvement?
Of course, I would first want to know if the disease was H. pylori+. Studies have shown that involved perigastric lymph nodes and deep invasion of the gastric wall are associated with a lower chance of achieving a complete response with triple therapy, but in most patients with gastric MALT (a very ...
How would you manage JAK2+ polycythemia vera during pregnancy and postpartum?
There are not a lot of data to guide us given the relative rarity of PV in adults of child-bearing age but two published studies may be helpful.An analysis of 129 pregnancies in patients with PV demonstrated that the combination of aspirin plus LMWH had a significantly lower risk of a spontaneous ab...
How would you treat ESRD patients on hemodialysis with recurrent AV fistula thrombosis found with low protein C activity?
I assume that the patient described in the vignette has a negative family and personal history of VTE. PC (and PS) deficiencies are relatively common in ESRD patients. The low levels are thoughts to reflect a combination of true (acquired) reduction and the assay interference rather than true defici...