Glaucoma and Uveitis Serrata ODS Secondary

to Imatinib Mesylate in Chronic Myeloid Leukemia

Sundarita, E.*, Norman Djamaluddin**, Mediarty***, Yenny Dian Andayani**

*Fellow of Medical Haematology Oncology, Faculty of Medicine, Sriwijaya University, Mohammad Hoesin Hospital, Palembang, South Sumatera, Indonesia
**Staff of Medical Hematology Oncology Division, Faculty of Medicine, Sriwijaya University, Mohammad Hoesin Hospital, Palembang, South Sumatera, Indonesia
***Head of Medical Hematology Oncology Division, Faculty of Medicine, Sriwijaya University, Mohammad Hoesin Hospital, Palembang, South Sumatera, Indonesia

INTRODUCTION

Chronic myeloid leukemia (CML) is a disease of haemopoietic stem cells, arising from Philadelphia
chromosome. The main treatment option for CML is monotherapy with BCR-ABL1 tyrosine kinase inhibitors
(TKI) such as imatinib. The most commonly observed adverse events (AEs) are hematologic (anemia,
neutropenia and thrombocytopenia) and nonhematologic AEs (nausea, vomiting, diarrhea, muscle cramps,
fluid retention, skin rash, and fatigue). While other less common AE such as glaucoma and uveitis.

CASE ILLUSTRATION

A 49 years old women, diagnosed with CML since 1 months ago with splenomegaly 10 cm below arcus costae, BCR-ACBL (+) and ELTS score 1,5867
(intermediate), treated with Imatinib mesylate 400 mg q.d. After 2 weeks Imatinib consumption, patients experience swollen on the both leg, left periorbital
edema and itching sensation. At physical examination, splenomegaly was unpalpable and laboratory finding revealed decreased number of leucocyte (181.25 x
103/mm3 to 26.57 x 103/mm3), while hematologic, hemostatic and renal function parameters between normal limit. Electrocardiogram and echocardiography
show normal condition. Opthalmologist examination reveal the glaucoma and uveitis serrata in both eyes. Imatinib were discontinued, patient switched to
Nilotinib 150 mg b.i.d, Furosemide 40 mg q.d., Cetirizine 10 mg b.i.d., Timolol ED 0,5% b.i.d., and Latanoprost ED q.d.

Pre- After
EYE EXAMINATION Imatinib Imatinib

Hb (gr/dl) 9.8 10.1

VOD 6/30 PH 6/15 VOD 6/30 PH 6/15
TIOD 13 mmHg TIOD 42,7 mmHg WBC (103/mm3) 155.34 26.57
Sinekia posterior 180° Sinekia posterior 180° PLT (103/µl) 411.000 360.10
AST (U/l) 15 16
ALT (U/l) 12 11
Bilirubin (U/l) 0,9 0.8

Spleen (cm below

10 Unpalpable
arcus costa)

DISCUSSION
CTCAEs Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Symptomatic with marked decrease in visual

Symptomatic; moderate decrease in visual acuity (best
corrected visual acuity 20/40 and better or 3 lines or
Blurred vision Intervention not indicated
less decreased vision from known baseline); limiting
instrumental ADL
Less <8 mmHg of elevated intraocular pressure EIOP which can be reduced to 21 mmHg or under with
Glaucoma
(EIOP); no visual field defect topical medication and no visual field deficit
Indurated or pitting edema, topical intervention
Periorbital Edema Soft or non-pitting
indicated
acuity (best corrected visual acuity worse than
Best corrected visual acuity of -
20/40 or more than 3 lines of decreased vision
20/200 or worse in the affected eye -
from known baseline, up to 20/200); limiting self
care ADL
Visual field deficit within the central
EIOP causing visual field deficits 10 degrees of the visual field in the -
affected eye
Edema associated with visual disturbance,
increased intraocular pressure, glaucoma or retinal
- -
hemorrhage, optic neuritis, diuretic indicated,
operative intervention indicated

Anterior uveitis with 3+ or greater cells; Best corrected visual acuity of 20/200
Uveitis Anterior uveitis with trace cells Anterior uveitis with 1+ or 2+ cells -
intermediate posterior or pan-uveitis or worse in the affected eye

Severe or medically significant but not

Asymptomatic or mild symptoms; additional Moderate, topical or oral intervention indicated;
Eczema immediately life-threathing; IV intervention - -
medical intervention over baseline not indicated additional medical intervention over baseline indicated
indicated

Widespread and constant, limiting self care ADL or

Pruritus Mild or localized, topical intervention indicated
5-10% inter limb discrepancy in volume or
circumference at point of greatest visible
Edema Limbs
difference, swelling or obscuration of anatomic
architecture on close inspection
Widespread and intermittent; skin changes from
sleep, systemic corticosteroid or - -
scratching
immunosuppressive therapy indicated
>10-30% inter limb discrepancy in volume or
circumference at point of greater visible difference;
>30% inter limb discrepancy in volume; gross
readily apparent obscuration of anatomic architecture;
deviation from normal anatomic contour; limiting - -
obliteration of skin folds; readily apparent deviation
self care ADL
from normal anatomic contour; limiting instrumental
ADL

CONCLUSION

The side effects of TKI are reported as ‘tolerable’ and ‘manageable’, but when the AEs, even minimal, even mild, are chronic, the quality of life and the
compliance to treatment will be affected. Consideration for switching TKI therapy should be done individually.

REFERENCES
1.Steegmann, J.L, Baccarani, M., Breccia, M. et.al. European Leukemia Net recommendations for the management and avoidance of adverse events of treatment in chronic myeloid leukaemia. Leukemia. 2016. 30: 1648–1671.
2.National Cancer Institute. US Department of Health and Human Services. Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0. 2017.
3.Payandeh, M., Sadghi, E., dan Masoud Sadeghi. Non hematologic adverse events of Imatinib in Patients with CML in Chronic Phase. Journal of Applied Pharmaceutical Science. 2015. 5: 02; 087-090.
4.NCCN Guidelines for CML, version 2.2020
5.ESMO Clinical Practice Guidelines of CML : Annals of Oncology 28 (Supplement 4): iv41–iv51, 2017.
 Syndrome of Inappropriate Antidiuretic Hormone Secretion
(SIADH)
Pada Pasien Geriatri : Laporan Kasus
Shahnaz, F.*, Alius Cahyadi**, Junaidi***, Nur Riviati**

*Residen Program Studi Pendidikan Dokter Spesialis Penyakit Dalam, Fakultas Kedokteran Universitas Sriwijaya, Rumah Sakit Dr. Moh. Hoesin Palembang, Sumatera Selatan
**Residen Adaptasi Program Studi Pendidikan Dokter Spesialis Penyakit Dalam, Fakultas Kedokteran Universitas Sriwijaya,
Rumah Sakit Dr. Moh. Hoesin Palembang, Sumatera Selatan
***Staf Divisi Geriatri, Departemen Penyakit Dalam, Fakultas Kedokteran Universitas Sriwijaya, Rumah Sakit Dr. Moh. Hoesin Palembang, Sumatera Selatan

PENDAHULUAN

Pada usia lanjut seringkali terjadi gangguan keseimbangan cairan dan elektrolit yang denga manifestasi dehidrasi,
hipernatremia dan hiponatremia. Hiponatremia adalah keadaan dimana kadar natrium di dalam darah <135 mEq/L.
Kecenderungan hiponatremia pada usia lanjut dapat disebabkan karena gangguan kemampuan ekskresi air yang
berhubungan dengan usia serta paparan terhadap obat dan penyakit yang berhubungan dengan hiponatremia.

ILUSTRASI KASUS

Seorang laki-laki, 71 tahun, berobat ke IGD dengan keluhan badan semakin lemas sejak 2 hari SMRS dan selera makan berkurang
sejak 1 minggu SMRS. Pasien mempunyai riwayat stroke pada tahun 2006, dan riwayat epilepsi paska stroke (3 bulan setelah terkena
stroke karena kejang berulang), memdapatkan terapi Fenitoin dan Natrium Valproat. Pasien lebih banyak berbaring di tempat tidur. Pada
pemeriksaan fisik didapatkan sudut mulut kanan tertinggal, plica nasolabialis kanan datar, deviasi lidah ke kanan, disartria (+). Pada pemeriksaan
penunjang laboratorium didapatkan hiponatremia (122 mEq/L) dan peningkatan kadar natrium pada urin (130 mmol/L). Pada
pemeriksaan penunjang CT Scan kepala tanpa kontras didapatkan kesan atrofi serebri senilis dan subcortical arteriosclerosis
encephalopathy. Pada pemeriksaan penunjang EEG didapatkan kesan perlambatan di frontoparietooccipital kanan, temporal kanan,
frontoparietooccipital kiri, dan temporal kiri.

Asesmen Geriatri Komprehensif

Asesmen Skor Definisi Keterangan

Pasien dalam
Penapisan Depresi Sulit Dinilai Tidak dapat dinilai
kondisi tidak sadar
Pasien dalam
MMSE 0 Tidak dapat dinilai
kondisi tidak sadar
Ketergantungan
ADL 1
total

MNA 7 Malnutrisi

DISKUSI

Laboratorium

Natrium serum 122 mmol/L FT4 1,13

Natrium urin 132 mmol/L T3 2,4

Osmolalitas serum 263 mmol/L TSH 1,25

Osmolalitas urin 443 mmol/L

REFERENSI
1. Spasovski, G., Vanholder, R., Allolio, B., Annane, D., et. al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. European Journal of Endocrinology. 2014; 170: G1-G47.
2. Lederer, E., Nayak, V., Disorder of Fluid and Electrolyte Imbalance. In: Hazzard’s Geriatric Medicine and Gerontology. 7th edition. 2017.
3. Woodward M, et al. Diagnosis and Management of Hyponatremia in the Older Patient. Internal Medicine Journal. 2018; 48 (Suppl.):5-12.
th ed.2017