Hem_Rheum_Oncology Flashcards
“<span>Complications post chemoRx</span>”
-Chemotherapy side effects<br></br>-Tumour lysis syndrome<br></br>-Gastroenteritis (viral or bacterial)<br></br>-Typhlitis<br></br>-Urinary tract infection<br></br>-Bowel obstruction (small or large)
Electrolytes disturbances of Tumor lysis syndrome:
HyperK<div>HypoCa</div><div>HyperPO4</div><div>Hyperuricemia</div>
DDx of monoarthritis
Septic joint<div>Gout</div><div>Pseudo gout</div><div>Reactive arthritis</div><div>RA</div><div>Spont hemoarthrosis</div><div>OA</div>
Gout vs Pseudogout
“<img></img>”
Therapies for SVC syndrome
Corticisteroids<div>Diuretics</div><div>Anticoagulation</div><div>Thrombolysis</div>
What are some specific treatments for SVC synd
Radiation<div>Chemotherapy</div><div>Surgery</div><div>Endovascular stent</div>
Risk factors for ALL
Chromosomal and (Philadelphia translocation)<div>Radiation exposure</div><div>ChemoRx for prior malignancy</div>
List 5 causes of fever in the cancer patient
- Infection (only identified in ⅓ of patients) <br></br>2. DVT / Pulmonary embolus <br></br>3. Chemotherapy or medication effect <br></br>4. Direct tumor burden effect <br></br>5. Transfusion reaction
List 4 causes of pericardial effusion in the cancer patient:
• Malignancy (lung, breast, hematologic, melanoma) <br></br>• Hypoalbuminemia <br></br>• Radiation <br></br>• Chemotherapy
Causes of hyperviscosity syndrome
<ol> <li>Elevation of cellular contents of blood (leukostasis, polycythemia)</li> <li>Cryoglobulinemic Hyperviscosity (e.g., Multiple Myeloma)</li> <li>Polyclonal or monoclonal immunoglobulins that are not cryoglobulins (e.g.,Waldenstrom’s macroglobulinemia)</li> <li>Partial obstruction by sickled RBCs</li> <li>Partial obstructed by parasitized cells (malaria, Babeiosis)</li> </ol>
How cancer patient get hypercalcemia?
PTHrP synthesis<div>Active vit D overproduction</div><div>Bone osteolysis (direct spread)</div><div>Ectopic PTH production</div>
Common Ca that mets to bone:
Breast<div>Lung</div><div><br></br></div><div>Kidney</div><div>Prostate</div><div>Testes</div><div><br></br></div><div>Myeloma</div>
Causes of SVC syndrome
Malignancy (lung,lymphoma)<div>Thrombosis (pacemaker)</div><div>Infections (endocarditid, mediastinitis, TB, syphilis)</div><div>Post radiation fibrosis</div>
CVS complications of SVC Malignancy:
SVC synd<div>DVT/PE</div><div>Dysrhythmias due to electr dist (hyperK)</div><div>Malignant pericrdial dis/temponade</div><div>Carotid blowout synd/carotid rupture</div>
Neurological complications of malignancy
<div><b>Infections: </b><br></br><i>Brain abscess<br></br>Meningitis<br></br>encephalitis</i><br></br></div>
<div><br></br><b>Vascular: </b><br></br><i>Leukostasis<br></br>Hyperviscosity syndrome</i></div>
<div><br></br><b>Electrolyte disturbances: </b><br></br><i>Hypercalcemia; <br></br>Hyponatriemia<br></br>SIADH</i><br></br></div>
<div><br></br><b>Mechanical :</b><br></br><i>brain mets, <br></br>spinal cord compression/cauda equina, <br></br>hydrocephalus</i></div>
Mx of Acute chest syndrome due to Sickle cell crisis
<p>Needs IV Antibiotics to cover CAP - Ceftriaxone and Azithromycin or Resp. Fluroquinolone (Chlamydia most common in sputum/Strep most common in Blood)</p>
<p>O2</p>
<p>IV Narcotics</p>
<p>Exchange Transfusion or Simple Transfusion</p>
<p>CT Chest - Infiltrate no PE</p>
<p>Hematology Consultation and ICU Admission</p>
“<h2><span>Classic Clinical Presentation for TTP</span></h2>”
“Never say “FAT RN” out loud in the ED or you might suffer bodily harm!<div><br></br></div><div>Fever</div><div>Anemia: microangiopathic H A, schistocytes</div><div>Thrombocytopenia</div><div>Renal insuff</div><div>Neuro abn <b>(the wholemark of TTP, HA, confusion, CN palsies, seizure, coma)</b></div>”
Mx of TTP in ER:
FFP (15 ml/kg)<div>Steroids (methylprednisolone)</div><div>Plasma exchange</div><div>Plt transfusion</div><div>Nephrology/hematology consult</div>
Minimum requirements to Dx TTP
MAHA<div>TCP</div>
Causative agent of HUS
E.Coli 0157:H7—Shiga toxin
3 abnormalities of HUS in blood work:
Low plt<div>Low Hb</div><div>Elevated creat</div><div>Schistocytes</div><div>Elevated LDH</div><div>Elevated Bilirubin<br></br><div><br></br></div></div>
Drugs should not be given in HUS:
AB<div>Antimotility agents</div>
<p>Name 3 clinical or lab criteria of TLS:</p>
<p><b>Clinical:</b> <br></br><i>renal failure, <br></br>renal stones, <br></br>gout, <br></br>tetany, <br></br>cardiac dysrhythmias.</i></p>
<p><b>Lab:</b><br></br><i>Increased uric acid, potassium, phosphate<br></br>Decreased calcium</i></p>
<p>What characteristics of cancer put a patient at high risk for TLS?</p>
<ul> <li>Rapid cell turnover</li> <li>Fast growth rate</li> <li>Large tumor burden</li> <li>Highly sensitive to chemo drugs</li> </ul>
<p>Bleeding sites that would suggest a coagulation pathway defect over a platelet pathway defect?</p>
<b>Coagulation pathway defect:</b><div> ICH</div><div> Joint bleeding</div><div> Bleeding into muscle</div><div><br></br></div><div><b>Plt pathway defect:</b></div><div> Mucocutaneous bleeding</div><div> GIB</div><div> GUB</div><div> Heavey menses</div><div> Petechiae</div><div> Epistaxis</div>
Causes of Micro and Macro cytic anemia:
<p>–<b>Microcytic</b> – iron-deficiency, thalassemia, anemia of chronic disease, sideroblastic (lead).</p>
<p>–<b>Macrocytic </b>– low B12, low folate, alcohol, liver disease, hypoT4, myelodysplastic</p>
Name indications of transfusion in anemia pt:
<p>–Symptomatic</p>
<p>–Evidence of tissue hypoxia</p>
<p>–Hemodynamically unstable</p>
<p>–Acute, ongoing bleeding</p>
<p>–Limited cardiopulmonary reserve</p>
What prothrombin comples concentrate (PCC) contain?
Vit K-dependent factors<div>Protein C</div><div>Protein S</div>
What is the major selling point of PCC over FFP?
<ol> <li>Rapidity of onset (reversal in 10 minutes)</li> <li>low volume.</li> <li>Less infectious risk.</li> <li>Less TRALI.</li> <li>Less allergic/transfusion reactions</li> </ol>
Complications of Blood transfusion:
Transfusion reaction:<div> Major ABO incompatibility</div><div> Febrile reaction</div><div> Allergic reaction</div><div> Delayed hemolytic reaction</div><div><br></br></div><div>Transfusion related acute lung inj (TRALI)</div><div>Infections (Viral, Bacterial)</div><div>Hypervolemia</div><div>Hypothermia</div>
<p>What is the most common cause of bacterial sepsis from pRBC transfusion?</p>
<p>–Yersinia enterocolitica</p>
<ul> <li>Name 5 triggers of DIC?</li> </ul>
“<p>–ILLNESS</p> <p>–Sepsis/infection: <em>Bonus – <span>what bacteria class is usually the culprit?</span> (<span>G -ve bacteria</span>)</em></p> <p>–Trauma</p> <p>–Transfusion reactions</p> <p>–ALI/ARDS</p> <p>–Pregnancy (abruption, HELLP, embolus etc)</p> <p>–Acute leukemia</p> <p>–Liver disease</p> <p>–Pancreatitis</p> <p>–Vasculitits</p> <p>–Envenomation: <em>Bonus – <span>which snakes</span>? (<span>Rattlesnake and vipers</span>)</em></p>”
<p>Name 5 lab tests you would like to order that you <u>expect </u>to be abnormal in DIC. For each test, state how the test will be abnormal.</p>
<p></p>
<p><b>CBC:</b></p>
<p><i>Low Hb<br></br>Low Plt<br></br>Schistocytes in peripheral smear</i><br></br><br></br><b>Coagulation profile:</b><br></br><i>Increased PT<br></br>Increased PTT<br></br>Increased D-Dimer<br></br>Low fibrinogen</i><br></br><br></br><b>LFT:</b><br></br><i>High bilirubin<br></br>High LDH<br></br>Low haptoglobin</i></p>
<p>Patient is oozing blood from everywhere. Fibrinogen is 60. How will you treat? What is your target fibrinogen level?</p>
<p>–Cryoprecipitate</p>
<p>–Target >100 (100-150)</p>
In DIC, when would you consider plt transfusion?
<p>–Bleeding + platelet level <50</p>
<p>–Any platelet level <10-20</p>
How much one unit of plt increase the plt count?
by = 50 in an adult
Indications of FFP:
<p>–Reversal of warfarin/vit K deficiency</p>
<p>–Massive transfusion</p>
<p>–Bleeding in a patient with multiple coagulation deficiencies – liver failure, DIC etc</p>
<p>–Bleeding in a patient with a factor deficiency that is not available – ex hemophilia</p>
<p>–FFP treatment generally monitored by PT/INR</p>
Indications of Cryoppt:
<p>–Bleeding with a low fibrinogen level (<100)</p>
<ul> <li>DIC, <em>liver disease, massive transfusion/dilution</em></li> </ul>
<p>–Bleeding in vWD</p>
<p>–If desperate in Hemophilia A (should use recombinant factor VIII)</p>
What does Cryoppt contain?
VIII<div>Fibrinogen</div><div>vWF</div>
Doses of FFP and Cryoppt:
Plasma: 15-20 ml/kg<div>CryoPPt: 2-4 bags/10 kg</div>
<p>Flowchart for consumptive thrombocytopenia</p>
“<p><img></img></p>”
DDX of polyarthritis:
Infection:<div> Lyme dis</div><div> Viral (parvovirus, hepatitis, rubella)</div><div> Gonococcal</div><div> Rheumatic fever</div><div>RA</div><div>Seronegative arthropathy (AS)</div><div>Reactive arthritis</div><div>SLE</div>
Features of reactive arthritis:
“Recent bact infection (venereal/diarrheal)<div> Salmonella, chlamydia, mycoplasma</div><div> campylobacter</div><div>Conjunctivits</div><div>Urethritis</div><div><br></br></div><div>Can’t pee, Can’t see, Can’t climb a tree</div>”
PPT factors for Sickle cell crisis
Cold<div>Dehydration</div><div>Infection</div><div>Stress</div><div>High altitude</div><div>Exercise</div>
C/F and complications of SCD:
<ul> <li>Acute chest syndrome</li> <li>Pain crisis</li> <li>Splenic infarction/sequestration</li> <li>Aplastic crisis</li> <li>CVA</li> <li>Bone pathology – infarction, osteomyelitis</li> <li>Hepatic infarction</li> <li>Priapism</li> <li>Hemolytic anemia</li> <li>Infection</li> </ul>
<p>What type of bacteria are SCD patients most susceptible and why?</p>
<p>–Encapsulated organisms (H.flu, S. pneumo)</p>
<p>–Functional asplenia from recurrent infarction</p>
<p>What bacteria must you think of in a SCD with osteomyelitis?</p>
Salmonella typhimurium
<p>Name 2 indications where exchange transfusion is considered.</p>
<p>–Acute chest syndrome</p>
<p>–CVA (especially in kids)</p>
<p>–Priapsim</p>
Define febrile neutropenia
Either: Temp > 38.3 once or > 38 for > 1 hr<div>ANC <500 (or <1000 and predict <500)<br></br><div><br></br></div></div>
Tests for febrile neutropenia:
Blood cultures x 2 sets<div>Urine culture</div><div>CXR</div><div>Sputum culture</div><div>Catheter culture (PICC line…etc)</div>
Micro-organisms for febrile neutropenia
Most common: staph/strept<div>Others:</div><div> Candida albicans</div><div> HSV</div><div> VZV</div><div> CMV</div>
<p>What 2 characteristics are you looking for when you choose your antibiotic regimen in febrile neutropenia?</p>
Broad spectrum<div>Bacteriocidal</div><div>Synergistic</div><div>Good SE profile</div><div>Low toxicity</div>
What AB would you choose in Feb neutropenia
Vancomycin<div>Meropenem</div><div>4th gen cephalo: cefipime/ceftazidime</div><div>PIP-TAZ</div>
Criteria for Dx of Acute chest synd of SCD
<b>1. Consolidation or infiltrate on CXR<br></br>2. At least 1 of the following: </b><br></br> <i>fever >38.5°C,</i><div><i> chest pain,</i></div><div><i> tachypnea,</i></div><div><i> cough,</i></div><div><i> wheezing, or</i></div><div><i> PaO2 <60mmHg</i></div>
Rx of bleeding due to vWD
Desmopressin (DDAVP)<div>Factor VIII</div><div>Cryoppt</div><div>TXA</div><div><br></br></div><div>Topical agents:</div><div>Fibrin glue</div><div>Thrombine spray</div>
Transfusion graft-vs-host disease
Serious adverse reaction which is usually fatal. It is rare, and it most commonly occurs in patients with:<div>immune defects,</div><div>lymphoproliferative disorders, or</div><div>those being treated with immunosuppressive agent of chemotherapy.</div>
Leukemias
“<img></img>”
Which type of leukemia causes gingival lesions
AML (acute myelogenous leuk)
Which drug can induce gingival hyperplasia
Phenytoin
Triad of HUS
MAHA<div>TCP</div><div>Renal failure</div>
vWD
More common in young females<div>Usual presentations are:</div><div>Heavey menses</div><div>PPH</div><div>Bleeding post dental procedures</div><div><br></br></div>
Transfusion Related Acute Lung Injury (TRALI)
is a rapid onset non-cardiogenic pulmonary edema that is <b>not </b>secondary to fluid overload and thus nitroglycerin and lasix should be avoided.<div> <i>Respiratory support,</i></div><div><i> supportive care,</i></div><div><i> IV fluids and</i></div><div><i> vasopressors if needed</i></div><div>are the mainstay of treatment.</div><div>Bronchodilation has no pathophysiological role in TRALI and thus albuterol would not be indicated.</div>
“<img></img><div>If the patient has SCD, what complication he could have?</div>”
“The child appears to be suffering from Fifth’s disease, an exanthem caused by Parvovirus B19. This virus can commonly cause transient aplastic anemia or crises in sickle cell disease patients.”
Most common cancers for TLS
“ALL<div>Non-Hodgkin’s lymphoma</div><div><br></br></div><div>less common for solid cancers</div>”
Acute potentially life-threatening SCD crises
Acute stroke<div>Acute chest syndrome</div><div>Aplastic crisis</div><div>Acute bacterial infection</div><div>Symptomatic anemia</div>
Poly arteritis Nodosa
Features:<div>Livedo reticularis</div><div>Intra-renal aneurysms</div><div><br></br></div><div>30% are ass w HBV</div><div>Rx: steroids</div>
Classic tetrad of HSP
Abd pain<div>Arthralgia</div><div>Purpuric rash</div><div>Renal impairment</div>
Compl of HSP
Intussusception
CREST synd
Calcinosis<div>Raynauds</div><div>Esophageal dysmotility</div><div>Scleroductyly</div><div>Telangiectasia</div>
Key features of Sarcoidosis
Bilateral Hilar LAP<div>Erythema nodosum</div><div>Increase in ACE levels</div>
Lab findings of sarcoidosis
Leukopenia<div>Eosinophilia</div><div>Elevated ESR</div><div>HyperCa</div><div>Elevated ACE levels</div>
Features of PCP pneumonia
elevated LDH,<div>hypoxia,</div><div>non-productive cough and</div><div>diffuse, bilateral alveolar infiltrates on x-ray</div>
What are the oncologic emergencies?
Febrile neutropenia<br></br>SVC syndrome<br></br>TLS<br></br>Hyperviscosity syndrome<br></br>Hyperuricemia<br></br>HyperK<br></br>HyperCa<br></br>Neoplastic cardiac temponade<br></br>Spinal cord compression<br></br>Raised ICP
Classical presentation of hyperviscosity syndrome
Bleeding<br></br>Visual dist<br></br>Neurological manifestations
Common primaries for cerebral mets
Lung<br></br>Breast<br></br>followed by:<br></br>Malignant melanoma<br></br>Kidney<br></br>GI
