One of my favorite symptom cluster's to manage is nausea and vomiting in cancer patients. My co-fellows at Duke have heard of my affinity for the role of psychopharmacologic agents, such olanzapine, in the management of chemotherapy-induced nausea and vomiting, to many times to count. Thus, when our team at Moi Teaching and Referral Hospital (MTRH) were consulted for a patient with metastatic melanoma, with symptoms of "refractory nausea and vomiting," I was hopeful to be able help this patient significantly with her symptoms.
Our patient, "Emily," a 42 year old Kenyan woman, had been diagnosed with malignant melanoma after she developed a dark lesion on her left hand several months prior to her presentation. She had a large (~2cm) mass on her left middle digit which was excised and found to have invasive melanoma. As is often the case in Kenya, she was lost to follow-up after the excision, and never had the mass fully treated with further surgical or oncologic management. So when Emily was admitted to MTRH with her symptoms it was concerning that her malignancy had progressed rapidly.
Emily presented to our hospital via "casualty," better known as the emergency department, for symptoms of headache, confusion, and severe refractory nausea and vomiting. Her symptoms unfortunately progressed to involve a right arm and leg weakness which eventually progressed to a total right hemiparesis. She initially was able to provide a medical history in the casualty department, however by the time of my assessment on her 3rd hospital day, she was completely aphasic (unable to speak).
The medical team had suspected a metastasis to her brain due to her underlying malignancy. Melanoma is a type of cancer which classically loves to metastasize to the brain, and patients often present with initial symptoms related to brain metastasis. Due to delays in the availability of a CT scan on admission, this had not been performed until the morning of my consultation.
Emily was uncontrollably nauseated, and was unable to eat or drink any food for the preceding 2 days. On exam she was awake, but minimally responsive to verbal or tactile stimuli and showed spastic tone on her right side diffusely. She was notably tachycardic and her breathing was rapid and shallow. She appeared quite ill. I expressed to my team a great worry that she had suffered an acute hemorrhage of a malignant metastasis due to her physical exam findings, and that her respiratory pattern was likely central in origin.
The general medicine team had been treating her nausea with a combination of Plasil (metoclopromide), a dopamine blocking agent used for nausea, and dexamethasone, a potent steroid, to reduce inflammation. Despite these treatments since admission, she continued to have severe symptoms of nausea and vomiting. I discussed with the oncology and general medicine team, a plan for rapid titration of her steroids, a switch from Plasil to haloperidol every 6 hours orally (only formulation we have available), and adding ondansetron IV every 8 hours. In the mean time, I discussed with some of my pharmacy colleagues the availability of olanzapine at MTRH as a back up tool. (I do love the stuff!)
Deep down however, I knew that her status was critical, and expressed my worry that she might not survive through the night. My team wondered aloud "how I could come to such a prognosis without the findings from her CT scan." I replied that, "all I really needed to do was examine her to know the extent of her neurologic injury." The CT scan will only "confirm" what I already saw with my eyes, and felt with my hands.When I returned later in the afternoon, her CT scan had been performed and my clinical officer asked me to interpret the films at the bedside. As I placed the hard copy of the images on the light box, a small crowd of Kenyan students gathered, and a collective cringe was palpable amongst the group. The scan revealed a massive area of tumor burden in the left frontal lobe, accompanied by evidence of acute hemorrhage, a great deal of surrounding vasogenic edema, and a significant amount of mid-line shift. The images essentially confirmed my exam, and my worries from morning rounds, that Emily was dying of impending cerebral herniation.
Emily took her final breath less than 48 hours after my consultation. Despite the teams best efforts, the biology of her illness was in the drivers seat, and the car was out of control by the time she presented to casualty. Her story is one that happens here at MTRH all to often.
In honor of Emily, I spent the weekend working on a presentation on the management of nausea and vomiting in oncology patients. It is my hope that the Kenyan medical students and residents, and I, can continue to learn from her unfortunate illness and its consequences.
