Sorafenib
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Sorafenib Inflammatory infiltrates in the soft tissues of the forearms and shoulders, thyroiditis and oesophageal erosion: case report
A 56-year-old woman developed inflammatory infiltrates in the soft tissues of the forearms and shoulders, thyroiditis and oesophageal erosion during treatment with sorafenib for acute myelomonocytic leukaemia (AMML). The woman, who had a history of multinodular euthyroid goitre, was diagnosed with AMML in December 2016. She subsequently underwent chemotherapy and achieved complete remission. However, she experienced a relapse in February 2018; hence, she started receiving fludarabine, high doses of cytarabine and idarubicin (FLAR-Ida program) for 2 courses as re-induction. However, no effect was noted. Thereafter, she started receiving daunorubicin, achieving the maximum allowable dose of 650 mg/m2; however, she developed signs of cardiotoxicity, including rhythm disturbances along with moderate enlargement of the atria and right ventricle of the heart. Therefore, she started receiving low-dose cytarabine. Eventually, sorafenib 400mg twice daily [route not stated] was added to her ongoing therapy. However, on day 10 of the sorafenib therapy, she developed paraproctitis accompanied by febrile fever [aetiology not specified], which was successfully treated with amikacin and cefoperazone/sulbactam. Later, on day 21, she developed a fever of 39°C, accompanied by inflammatory infiltrates in the soft tissues of the forearms and shoulders. However, all tests for infectious aetiologies at this time were found negative. The woman received unspecified carbapenems, following which her infiltrates gradually disappeared; however, her temperature remained high (38.0–39.5°C). She also received amphotericin-B and tedizolid, but without effect. Gradually, single new infiltrates of the soft tissues of the forearms and shoulders appeared. On day 23 of sorafenib therapy, she reported discomfort in the throat while swallowing. Examination revealed that the pharynx was moderately hyperaemic. The neck region was normal. Her thyroid gland was enlarged, was accessible on palpation (degree II as per the WHO classification), and caused no pain. The soft tissues surrounding the gland were slightly hyperaemic and oedematous; however, thyroid hormones, thyroglobulin and thyroid peroxidase antibodies were normal. Ultrasound revealed an enlarged thyroid gland with increased echogenicity and moderate diffuse changes. The volume of the gland increased to 50cm3. Colour Doppler mapping did not reveal increased blood flow, characteristic of hypertrophic autoimmune thyroiditis. CT scans showed an enlarged thyroid gland, with oedema of the surrounding tissue. On MRI, the thyroid gland had a heterogeneous enhancement of the MR signal from the parenchyma with hypointense inclusion on the right and hyperintensive on the left. Endoscopic examination demonstrated oesophageal erosion with signs of completed oesophageal bleeding; however, the pharynx and larynx were unchanged. The size of her thyroid gland continued to in
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