The bite of a brown recluse spider ( Loxosceles reclusa ) is usually associated with skin necrosis; however, it can lead to more significant morbidity including acute hemolytic anemia, rhabdomyolysis, disseminated intravascular coagulopathy and death. Here we highlight a case using plasmapheresis as treatment for acute hemolytic anemia caused by the bite of a brown recluse spider. A 49-year-old male presented to the emergency room 5 days after suffering a spider bite due to worsening symptoms. He had worsening pain at the site of the bite, diffuse body myalgias, darkening of his urine, chills, and shortness of breath. Hematology was consulted to assist in the management of hemolytic anemia refractory to multiple blood transfusions, worsening acute kidney failure requiring hemodialysis, and concern for impending death. After a literature review suggesting plasmapheresis may be beneficial in this scenario, the case was discussed with the local blood bank, and plasmapheresis was initiated. The patient underwent plasmapheresis with albumin for 2 days and the patient’s hemoglobin improved and stabilized. Therapy of loxoscelism is directed at limiting the dermatonecrosis at the site of the envenomation and in cases of systemic illness supportive care is recommended. Therapeutic plasma exchange has been shown efficacious in treating snake envenomation, but there are limited data detailing its use for brown recluse spider envenomation. Here we present a case to highlight the benefit of plasmapheresis in a patient with acute hemolytic anemia secondary to a brown recluse spider bite.

e13041 Background: PIK3CA mutations occur in about 40% of patients with HR+/HER2- breast cancer. The phase III SOLAR-1 trial demonstrated prolonged progression-free survival with alpelisib and fulvestrant compared to fulvestrant alone among patients with HR+/HER2-/ PIK3CA mutant advanced breast cancer previously treated with endocrine therapy. Hyperglycemia was seen in 64% of patients treated with alpelisib and fulvestrant and was treated with metformin. Inhibition of PI3Kα leads to an on-target effect of hyperglycemia and a secondary hyperinsulinemia. This rebound hyperinsulinemia may lead to escape PI3K pathway activation in breast cancer progression via the insulin and IGF1pathways. Concurrent administration of SGLT2 inhibitors may abrogate the PI3K pathway activation effect and delay disease progression. This study reports time on treatment with alpelisib and PFS among patients who received an SGLT2 inhibitor with alpelisib. Methods: A retrospective review of all metastatic breast cancer patients treated with alpelisib was completed from 8/2019 to 5/2021 at the Saint Luke’s Koontz Center for Advanced Breast Cancer. Results: This review included 22 female patients, 11 received an SGLT2 inhibitor for treatment related hyperglycemia (A+SGLT group) and 11 who received metformin/other diabetic agents (A group). Baseline characteristics were not significantly different between the two groups: median age 63, BMI of 29.1, hemoglobin A1C of 6.3 and fasting blood glucose of 119.1mg/dl. PIK3CA mutations included H1047X (40.9%), E545X (31.8%), E542K (13.6%), other (13.6%). The median number of prior treatments for MBC was 3 (range 1-5). Prior treatments included aromatase inhibitors: 100%, fulvestrant: 77%, CDK 4/6 inhibitors: 82%, everolimus: 32% and chemotherapy: 68%. Hyperglycemia grade 2+ was seen in 72.7% of patients. There were no significant differences between the two groups for emergency room visits, hospitalizations, or endocrinology referrals related to hyperglycemia. Median time to initiation of an SGLT2 inhibitor was 13 days following the first dose of alpelisib. PFS was longer in the A+SGLT compared with the A group with a median time to progression of 6.1 months and 3.9 months respectively (HR 0.51; 95% CI 0.16 to 1.63; p = 0.39). Time on treatment was significantly longer for A+SGLT group compared with the A group, with a median time on treatment of 5.8 months, compared with 3.0 months (HR 0.32; 95% CI 0.11 to 0.92; p = 0.03). The primary reason for discontinuation of alpelisb was disease progression in 73%, with no statistically significant difference in the reason for discontinuation between the groups. Conclusions: This study supports a potential clinical benefit of an SGLT inhibitor along with alpelisib in allowing for a longer time on treatment, without significant adverse events. It also suggests a possible favorable impact on PFS for the combination.

Multiple myeloma is a plasma cell neoplasm characterized by clonal proliferation of immunoglobulin producing terminally differentiated B cells. Classically patients are described to present with bone pain, hypercalcemia, anemia, and/or renal impairment. A less described clinical manifestation related to the myeloma is acquired coagulation abnormalities including paraprotein interfering with the coagulation cascade or exhibiting specific antibody activity. Factor X deficiency is reported in patients with secondary amyloidosis. We describe a patient who presented with bleeding tendency and an abnormal prothrombin and activated partial thromboplastin times (PT/PTT) due to factor X deficiency. A thorough workup revealed the diagnosis of multiple myeloma with the presence of monoclonal lambda light chain restricted plasma cells with qualifying end-organ damage without evidence of amyloidosis. Prior to the ultimate diagnosis, the patient succumbed to septic shock and acute respiratory distress syndrome due to Streptococcus Pneumonia infection.

e24200 Background: The Distress Thermometer (DT) is a tool used to evaluate distress among cancer patients. The DT can provide information for intervention recommendations such as social work, psychological, and other ancillary services. The National Comprehensive Cancer Network (NCCN) recommends recurrent use of the tool. The DT is widely used as a standard of care for an initial screening of cancer patients, but data on subsequent use is lacking. The aim of this research was to evaluate repeat DT scores in a heterogeneous cancer patient population. Methods: Clinical investigators conducted a longitudinal study of DT ratings for cancer patients receiving outpatient care at a community-based oncology subspecialty practice in a mid-sized city from 2018 to 2019. Study objectives included reviewing referrals and evaluating the relationship between the initial screening and the screening at the 6-month checkup. The Distress Thermometer was used (i.e., 0-10; zero is “no distress” and ten “extreme distress”) with scores of four or greater regarded as a signal of greater risk for patient distress. Results: The study sample included 79 patients with an average score of 4.3 and 4.0 at baseline and the 6-month screening, respectively. Patient referrals included physical and emotional therapy (n=1) or social/psychosocial worker assessment (n=26). Patients with a documented referral had a crude 1.7 (95% CI: 0.6, 3.3) greater point decrease in scores compared to patients not offered a service referral. When adjusting for baseline scores and the time between scores, referral accounted for 1% (95% CI: 0%, 14%) of variability in score changes, while baseline scores accounted for 40% (95% CI: 22%, 52%) and time accounted for 3% (95% CI: 0%, 14%). Conclusions: Study results reveal a possible decrease in higher scores from the initial screening to the 6-month check-up. Patients with a referral did not have their service utilization confirmed and this study failed to show an additional decrease in scores based on referrals when controlling for baseline score and time. Most previous research has focused on one specific cancer type. This study revealed the possible importance in understanding DT scores in a heterogenous cancer patient population. Furthermore, large scale research is needed to confirm preliminary data and further expound on distress at initial and subsequent screenings after interventions. A better understanding of this content area may function to improve future care and patient well-being.

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