A 69-year-old female patient was admitted to receive CAR T-cell therapy for her primary
refractory stage IV diffuse large B-cell lymphoma. Initial diagnosis had been made
11 months before in the context of an upper GI bleeding from an ulcerating stomach
tumor. Upon admission, the patient had stable disease. By day+8 the patient presented
with fulminant hematemesis triggering immediate transfer to ICU. The patient was admitted
with a blood pressure of 80/50 mmHg and tachycardia of 130 bpm, also showing centralization
and reduced vigilance. Protective intubation was performed with a short resuscitation
during the procedure due to a PEA. Two vasopressors were required due to rapidly progressive
hemodynamic instability. Eight red blood cell concentrates, 4 platelet concentrates,
2 FFP and 4 g Fibrinogen were transfused. Emergency EGD identified severe arterial
bleeding in the corpus within an ulcerated area. The initial attempt to control the
bleeding with TTSC after injection of adrenalin was unsuccessful, consequently an
OTS-clip was applied. With further bleeding next to the primary localization, a second
OTS-clip finally achieved successful hemostasis, leading to better sight clearly showing
the spleen behind a completely destructed stomach wall. Further detailed inspection
detected a large splenic artery as the source of bleeding with no possible further
endoscopic interventions. Interventional angiography was also denied because of severe
instability. Unfortunately, the patient died from refractory hemorrhagic shock 2.5
hours after ICU admission. Although unproven, fatal bleeding might have been caused
by rapid tumor shrinking upon treatment, that might have uncovered large arteries
arroded by the lymphoma.
