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      A rare case of lung carcinoma acquires multidrug-resistant Klebsiella pneumoniae pneumonia radiologically mimicking metastasis caused by nivolumab therapy-associated neutropenia

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          Abstract

          Nosocomial infections by Klebsiella pneumoniae, especially those due to multidrug-resistant strains, are being increasingly detected. In this report, we present the case of a 63-year-old man with lung squamous carcinoma who received nivolumab therapy due to failure of first-line chemotherapy. This report also demonstrates an association of nivolumab therapy and neutropenia, and supports the use of a combination of tigecycline and meropenem in managing hospitalization-acquired pneumonia caused by multidrug-resistant K. pneumoniae. It also implicates that a further evaluation is required in lung cancer patients with a suspected metastatic or recurrent carcinoma, and an antibiotic therapy is valuable in ruling out a potential lung infection since a risk of hospitalization-acquired pneumonia may exist.

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          Most cited references 5

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          Treating infections caused by carbapenemase-producing Enterobacteriaceae.

          Carbapenemase-producing Enterobacteriaceae (CPE) have spread worldwide, causing serious infections with increasing frequency. CPE are resistant to almost all available antibiotics, complicating therapy and limiting treatment options. Mortality rates associated with CPE infections are unacceptably high, indicating that the current therapeutic approaches are inadequate and must be revised. Here, we review 20 clinical studies (including those describing the largest cohorts of CPE-infected patients) that provided the necessary information regarding isolate and patient characteristics and treatment schemes, as well as a clear assessment of outcome. The data summarized here indicate that treatment with a single in vitro active agent resulted in mortality rates not significantly different from that observed in patients treated with no active therapy, whereas combination therapy with two or more in vitro active agents was superior to monotherapy, providing a clear survival benefit (mortality rate, 27.4% vs. 38.7%; p <0.001). The lowest mortality rate (18.8%) was observed in patients treated with carbapenem-containing combinations.
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            Partial Remission of Hepatic Metastatic Lesion but Complicated with Secondary and Refractory Fever Lead by Nivolumab in a Patient with Lung Adenocarcinoma Presenting Gefitinib Acquired Resistance

            To the Editor: Nivolumab, an antibody that blocks the immune-checkpoint inhibitor programmed cell death protein 1 (PD-1), has recently shown some promising results in clinical trials for all nonsmall cell lung cancer subtypes.[1 2] It is required that clinic practice about anti-PD-1 antibodies provided real data never observed in previously known clinical trials. In addition, It is also needed to assess the role of nivolumab in the subsequent therapy of tyrosine kinase inhibitor (TKI) acquired resistance. A 60-year-old Chinese woman having a 1 month history of a dry cough was taken to the outpatient of the First Hospital of Taicang City. A chest computed tomography (CT) scan revealed a mass lesion (3 cm × 2 cm) on the right hilus. An abdominal CT showed multiple solid lesions in the liver [Figure 1a]. Clinically, bronchoscope biopsy and histopathological examination revealed lung adenocarcinoma (Stage IV). Chemotherapy, in which the regimen included pemetrexed at 500 mg/m2 in combination with cisplatin at 75 mg/m2, was administered with standard premedication. Due to the poor clinical status, gefitinib was alternatively administered at a daily dose of 250 mg. A good response to gefitinib was observed in lung, but the liver metastasis had clearly increased after 30 months of TKI therapy [Figure 1b]. At that point, we decided to treat the patient with nivolumab. After two courses of a single dose of nivolumab treatment at 2 mg/kg, radiographic examinations demonstrated a significant improvement in the liver lesions [Figure 1c]. Figure 1 (a) Metastatic hepatic carcinoma at diagnosis. (b) The liver metastasis had clearly increased after 30 months of TKI therapy. (c) Anti-PD-1 antibody lead to partial remission of hepatic metastatic carcinomas. (d) Within the window of follow-up (n = 35 days), secondary fever was presented in the case after receiving anti-PD-1 antibody therapy. TKI: Tyrosine kinase inhibitor; PD-1: Programmed cell death protein 1. However, about 1 week after the first course of nivolumab treatment, continual fevers were recorded. The co-infection was ruled out based on the negative microbiological testing and the absence of infectious symptoms. Hematologic and biochemical tests were in the normal range. A CT scan identified bilateral pleural effusion but no consolidation or progression of the primary tumor. The results of pleural effusion tests were indicative of transudate. Patient's serum levels of anti-native DNA, anti-nuclear, and anti-cardiolipin antibodies were within the normal range. Taking into account the result of extensive medical tests, we applied methylprednisolone (1.5 mg/kg) for 1 week, followed by oral prednisone at a dosage of 0.5 mg/kg of body mass a day. However, the fever of the patient was not improved during the follow-up [Figure 1d]. Immunotherapy is rapidly being integrated into oncology practice and is poised to alter the therapeutic landscape for a variety of malignancies. However, there are still some reports which pointed out that a certain proportion of Grade 3 or 4 immune-related adverse events (irAEs) of PD-1/PD-L1 inhibitors occurred.[3] Taken together, it was a rare case that exhibited the efficacy of nivolumab on progressive hepatic metastatic carcinomas resulting from TKI acquired resistance in the real world. As an irAEs, the patient suffered from adverse event shortly after administration of nivolumab and manifested with refractory and continual fever even treatment withdrawal. Financial support and sponsorship This work was supported by a grant from Key Talent of Suzhou Health (2015, to Cheng Chen). Conflicts of interest There are no conflicts of interest.
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              Pulmonary tuberculosis with false-positive 18F-fluorodeoxyglucose positron emission tomography mimicking recurrent lung cancer: a case report

               C. CHEN,  YH Zhu,  HY Qian (2015)
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2017
                12 October 2017
                : 13
                : 1375-1377
                Affiliations
                Respiratory Department, The First Affiliated Hospital of Soochow University, Suzhou, People’s Republic of China
                Author notes
                Correspondence: Ye-han Zhu; Cheng Chen, Respiratory Department, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, People’s Republic of China, Email zhuyehansz@ 123456sina.com ; chenchengatsd@ 123456sohu.com
                [*]

                These authors contributed equally to this work

                Article
                tcrm-13-1375
                10.2147/TCRM.S144681
                5644596
                © 2017 Liu et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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