Objective: Hematopoietic stem cell mobilization increases the release of immature and maturing hematopoietic cells from the marrow into the blood circulation. For successful hematopoietic stem cell transplantation an adequate number of stem cells must be mobilized and collected. For autologous stem cell transplants, a product bag CD34+ count of > 5.0 x 106 CD34/kg is a target; however, patients have been successfully transplanted with doses as low as 2.0 x 106 CD34/kg. Some patients are "poor mobilizers" and standard protocols do not result in adequate numbers of circulating CD34 cells to collect. Risk factors associated with poor stem cell mobilization include increasing age, underlying diagnosis, low premobilization platelet count, history of increasing cycles, and regimens of chemotherapy. Teriparatide, a parathyroid hormone (PTH) analog has been used in "poor mobilizers." Two patients at our institution received the drug as part of an additional mobilization strategy. Method: Medical records of patients who had stem cell mobilization were reviewed. Two patients who failed routine mobilization protocol received PTH as part of an additional mobilization regimen. Clinical outcomes, collection, and engraftment data were reviewed. Result: Patient 1 had a diagnosis of Hodgkin Lymphoma and failed to mobilize adequately on the first attempt using filgrastim and plerixafor with peripheral blood CD34 counts of 1, 4, and 3 resulting in cancellation of stem cell collection. For the second mobilization attempt, teriparatide was added to the regimen. Peripheral blood CD34 counts improved to 8, 6, and 2 resulting in three collections with a total of 2.23 x 106 CD34/kg for reinfusion. Engraftment data showed 14 days for neutrophils and 17 days for platelets. The patient is 6 months post-transplant with no major morbidities reported, currently in maintenance therapy, and has not recurred. Patient 2 had a diagnosis of multiple myeloma and failed to mobilize on filgrastim and plerixafor with peripheral blood CD34 counts of 2, 2, and 2 resulting in collections with a total of 0.6 x 106 CD34/kg for reinfusion. For the second mobilization attempt, peripheral blood CD34 counts of 2, 2, 2, and 0 resulting in collections with a total of 0.822 x 106 CD34/kg for reinfusion. For the third mobilization attempt, teriparatide was added to the regimen. Peripheral blood CD34 counts improved to 8 and 4 resulting in collections with a total of 1.8 x 106 CD34/kg for reinfusion. Patient expired one month after collection without reinfusion. Conclusion: Two patients who failed standard mobilization for stem cell collection at our institution received teriparatide as part of an additional stem cell mobilization regimen. Adequate doses of stem cell products for transplant were collected. One patient was reinfused and subsequently engrafted appropriately. Teriparatide can be used in the setting of poor mobilization. Disclosures No relevant conflicts of interest to declare.

Sera from patients with multiple myeloma usually display a single monoclonal immunoglobulin band on serum protein immunofixation electrophoresis. Multiple bands may be seen if the myeloma is bi- or triclonal or if the monoclonal immunoglobulin has rheumatoid factor activity. We describe a patient with light chain–predominant IgA lambda myeloma; the patient’s serum displayed 2 spatially distinct bands reacting for alpha heavy and lambda light chains. The methods used to establish monoclonality are addressed.

Cytomegalovirus (CMV) is a double-stranded DNA virus, which infects a large portion of the adult population. In immunocompetent patients, it typically is asymptomatic or manifests as mild and self-limiting flu-like illness symptoms, whereas in immunocompromised patients, CMV can cause significant disease. Herein we report an unusual case of CMV pancreatitis in an immunocompetent 75-year-old female. Patient developed severe significant pancreatic necrosis that failed non-operative management, and ultimately underwent pancreatic necrosectomy. Later on, she developed three spontaneous gastric perforations. The first two perforations were managed operatively, but after the third perforation family decided not to undergo another operation. The CMV pancreatitis diagnosis was based on pancreatic histopathology and confirms by a prompt response to ganciclovir. Patient was promptly started on intravenous (IV) ganciclovir which resulted in clinical recovery and she remained asymptomatic more than one-year post op. This is a rare case of CMV pancreatitis with gastric perforations in an immunocompetent patient. High degree of suspicion and appropriate treatment are important for such clinical scenarios.

Objectives Obesity predisposes to multiple diseases, such as heart disease, diabetes, stroke, arthritis, and malignancy. However, obese patients have better outcomes than normal-weight patients with some of these disorders, including those admitted to critical care units. We compared the results for common laboratory tests in patients with uncomplicated obesity against the findings in normal-weight patients. Methods Patients who had a comprehensive metabolic profile test were identified. Patients with acute and/or chronic debilitating disorders were excluded, and the laboratory parameters were compared among 4 groups based on body mass index. Results With the exception of elevated triglycerides and lower high-density lipoprotein in obese and morbidly obese patients, laboratory findings were not meaningfully different from those in normal-weight patients. Conclusions The obesity paradox of better outcomes in obese patients admitted to critical care units could not be explained on the basis of lower additional disease burden necessitating critical care admission due to abnormal laboratory values at the baseline. It is conceivable that unconscious bias against obese patients, with lower disease burden than normal-weight patients, triggers their admission to critical care, thus creating the appearance of better outcomes.

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