A 67-year-old patient visited the hospital for the evaluation of pulmonary nodular lesions detected in his chest radiograph during an annual screening. He was asymptomatic and transbronchial tumor biopsy of the nodule in the right upper lobe revealed features of pulmonary sarcoma, which did not resemble any of the histolopathological categories of primary lung cancer. A positive immunological staining for both HMB-45 and Melan-A resulted in the final diagnosis of melanoma. It is important for a respiratory clinician to remind the possibility of a melanoma, when tumors cannot be histopathologically classified under any of the categories of primary lung cancer.

Objective To report a case of leukocytosis (LCT) and hyperleukocytosis (HLCT) episodes post Pegfilgrastim (Neulasta) administration.

Case Summary A 74-year-old female presented with several episodes of LCT and HLCT following administration of Pegfilgrastim while undergoing adjunct dose dependent chemotherapy for adenocarcinoma of the gallbladder. The patient had completed cycle 6, day 8 of chemotherapy and subsequently received Neulasta 48 hours later. Two days later, she presented to the ER with white blood cell (WBC) count of 110K. Prior to Neulasta administration, her WBC counts were within normal range and after each episode of leukocytosis, the patient’s WBC count trended downward. Upon consultation, hematology considered Pegfilgrastim as a likely cause for this patient’s WBC cycling and HLCT.

Discussion Pegfilgrastim-induced HLCT occurs in less than 1% of patient cases. Dose-dependent chemotherapy combined with Pegfilgrastim treatment is an optimal treatment option to reduce the length of chemotherapy schedules and risk of febrile neutropenia. Following the dosing of Pegfilgrastim, the drug clearance is mediated by neutrophil receptors which results in a reduction of ANC values.

Conclusions Further studies are needed to determine the optimum timing and dosage of Pegfilgrastim to offer maximum myeloprotective benefit while also minimizing the risks of adverse events such as leukocytosis and hyperleukocytosis experienced by our patient.

Treatments for COVID-19 infection have varied widely within the past year. Remdesivir is the only direct-acting antiviral approved by the Food and Drug Administration with demonstrated efficacy in the management of patients with COVID-19.[1] Commonly reported adverse effects include hepatotoxicity and gastrointestinal symptoms such as nausea and diarrhea. Less common adverse effects include respiratory toxicity, cardiovascular toxicity and nephrotoxicity.[2] We report a case of international normalized ratio (INR) prolongation in a COVID-19 patient receiving concomitant warfarin and remdesivir therapy.

Adenosquamous carcinoma (ASC) of the esophagus is a rare malignancy of the esophagus with histopathologic features of both adenocarcinoma and squamous cell carcinoma. Given the rarity of this disease, there is scant literature on ASC. We report a unique case of a 29-year-old African American female with advanced ASC manifesting as a pathologic fracture. Magnetic resonance imaging (MRI) confirmed femoral fracture, and femoral biopsy demonstrated metastatic ASC. Upper endoscopy revealed a distal esophageal stricture, and histopathology confirmed ASC. To our knowledge this is the youngest case of ASC to be reported. We discuss ASC epidemiology, clinical findings, diagnosis, and current treatments.

Cardiovascular manifestations of COVID-19 infection remain an ongoing study. We present a case of significant bradycardia in the patient with COVID-19 sepsis. We discuss about the possible mechanism, pathophysiology, and management in this pathology.

Hepatosplenic T cell lymphoma (HSTCL) is an exceedingly uncommon, aggressive peripheral T cell lymphoma comprising < 1% non-Hodgkin’s lymphomas (NHL). Despite treatments including allogeneic stem cell transplantation, median survival is < 2 years. In the majority of patients, the etiology of HSTCL is undetermined; although it has been associated with chronic immunosuppression which accounts for 20% of cases. HSTCL presents as a systemic illness, and sometimes in association with hemophagocytic lymphohistiocytosis syndrome (HLH). Our patient is a young male with a long-standing history of Crohn’s disease on immunosuppressive medications, who presented with progressive bicytopenia. He was diagnosed with HSTCL on a bone marrow biopsy and met clinical diagnostic criteria for HLH. He was started on chemotherapy and dexamethasone per HLH treatment protocol and underwent allogeneic hematopoietic stem cell transplantation (HSCT).