Heme Lymph CIS Handout Flashcards
Possible symptoms of CLL
Painless swelling of LNs, often in cervical area, which spontaneously wax and wane but do not disappear
Most pts feel entirely well with no symptoms and diagnosis is made based on routine blood count showing absolute lymphocytosis
5-10% will have B symptoms (fever, weight loss, drenching night sweats, extreme fatigue)
Most common abnormal finding on PE of a pt with CLL
LAD — most commonly cervical, supraclavicular, and axillary [described as firm, rounded, discrete, nontender, and freely mobile upon palpation]
Second most frequently enlarged organ in CLL
Spleen
[usually painless and nontender to palpation]
Besides the common findings of LAD and splenomegaly, what are some other PE findings associated with CLL?
Hepatomegaly
Leukemia cutis (skin is most commonly involved non-lymphoid organ) — usually involves the face and can manifest as macules, papules, plaques, nodules, ulcers, or blisters
Virtually any lymphoid tissue may be enlarged at dx, including Waldeyer’s ring in the pharynx [Note: in contrast to other lymphomas, clinically relevant GI mucosal involvement is rarely seen in CLL. Similarly, meningeal leukemia is unusual at the time of initial presentation]
MGGN has occasionally been described in CLL: paraneoplastic deposition and possibly processing of cryoprecipitating or noncryoprecipitating M-components
The most noteworthy lab abnormality found in CLL is lymphocytosis in the peripheral blood and bone marrow. What is the absolute blood lymphocyte threshold for diagnosing CLL?
> 5000/microliter [5x10^9/L]
Note: a significant proportion of pts present with counts as high as 100,000/microliter
Other than lymphocytosis, what other lab abnormalities are associated with CLL?
Cytopenias — neutropenia, anemia, and thrombocytopenia (usually not severe)
Immunoglobulin abnormalities — hypogammaglobulinemia (may affect IgG, IgA, and/or IgM)
The above findings contribute to increased vulnerability of CLL pts to major bacterial infections
What are the implications of cytopenias seen in CLL?
Increased incidence of autoimmune hemolytic anemia (AIHA) — thus the direct antiglobulin (Coombs) test (DAT) may be positive at some time during the course of the disease in up to 35% of cases
Pure red cell aplasia (rare)
Autoimmune thrombocytopenia is suggested when a bone marrow biopsy shows adequate numbers of megakaryocytes
Agranulocytosis (rare)
Diagnostic evaluation of a pt suspected of having CLL should include what?
CBC with diff
Exam of peripheral smear
Immunophenotypic analysis (flow cytometry) of circulating lymphocytes
[bone marrow aspirate/bx and LN bx are not required elements of diagnostic workup; chromosomal changes in CLL are not diagnostic features of the disease]
Morphology associated with CLL
Peripheral smear shows lymphocytosis (small, mature appearing lymphocytes with dense nucleus)
These PROLYMPHOCYTES usually account for minority of overall lymphocyte population. The smear often contains SMUDGE cells (aka BASKET cells)
2 criteria that must be met to make dx of CLL
Absolute B lymphocyte count in peripheral blood >5000/microL with a preponderant population of morphologically mature-appearing small lymphocytes
Demonstration of clonality of the circulating B lymphocytes by flow cytometry of peripheral blood (majority should express extremely low levels of SmIg and either kappa or lambda light chains; expression of B cell associated antigens — CD19, CD20, CD23; and expression of T cell associated antigen CD5
What are the prognostic variables on the CURB-65 mortality prediction tool for pts with community-acquired pneumonia?
Confusion BUN > 20mg/dL RR >30 breaths/minute BP (syst <90, diast <60) Age > 65
[0-1 points tx as outpatient, 2 pts tx as inpatient, >3 pts tx in ICU]
The following are genetic features of what neoplastic entity:
Deletion 13q, trisomy 12, deletion 11q, deletion 17p, TCR genes not clonally rearranged
CLL/SLL
Absolute increase in number of clonal B cells in peripheral blood does not exceed 5000/microL w/ immunophenotype identical to CLL, and pts have no LAD, organomegaly, cytopenias, or other symptoms
Monoclonal B cell lymphocytosis
> 55% of circulating lymphocytes are prolymphocytes; bone marrow is infiltrated in an interstitial or nodular pattern by similar cells
Express bright surface IgM +/- IgD and bright CD20 as well as other B cell Ags (CD19, CD22, CD79a, FMC7)
No associated paraproteinemia; TCR genes not rearranged
B cell prolymphocytic leukemia
t(11;14)
Mantle cell lymphoma
Unlike CLL, most cases of ____ are negative for CD5, express CD11c, CD103, CD123, cyclin D1, and/or annexin A1
HCL
Can have a leukemic phase that mimics CLL morphologically with circulating small lymphocytes with irregular or cleaved nuclei. Like CLL, coexpress CD20 and CD5 and do not express CD23 but stain strongly for cyclin D1 and surface membrane Ig
Mantle cell lymphoma
Peripheral blood involvement is usually less prominent; circulating malignant cells have plasmacytoid appearance; lacks CD23 expression and stains strongly for surface IgM, CD20, and cytoplasmic Ig
Lymphoplasmacytic lymphoma
Guidelines for pneumococcal vaccine in CLL pts (PCV13 and PPSV23)
Give PCV13 followed by PPSV23 at least 8 weeks later
Administer second dose of PPSV23 at least 5 years after the first dose of PPSV23
Vaccines that are recommended in immunocompromising conditions such as CLL
Influenza vaccine annually
Tdap then Td every 10 years
HPV (3 doses through age 26)
PCV13 and PPSV23
[meningococcal, Hep A, and Hep B recommended if some other risk factor is present; Hib is recommended for post-HSCT recipients only]
Vaccines that are contraindicated in immunocompromising conditions such as CLL
Varicella
Zoster
MMR
Common etiologies of community acquired PNA in outpatients
In order of frequency:
Unknown M.pneumoniae Respiratory viruses S.pneumoniae Chlamydophila pneumoniae Legionella Haemophilus influenzae
Most common (known) cause of community acquired pneumonia in hospitalized pts
S.pneumoniae
[others include respiratory viruses, legionella, M.pneumoniae, etc.]
Biomechanical OMM considerations for PNA pt
Indirect OMT to all somatic dysfunctions — especially cervicals, scalenes, pectorals, ribs, thoracics, diaphragm
Resp-circ OMM considerations for PNA pt
Treat zink patterns — suboccipital release, TI release, diaphragm release with vacuum modification
Tapotement/cupping/slapping to break up consolidation (potential relative contraindication pending further investigation of abnormal CBC in CLL pt)
Neurologic OMM considerations for PNA pt include chapman’s points, somatic nervous system, and autonomic nervous system.
What are the anterior chapmans points associated with heart/bronchi/esophagus, upper lung, and lower lung?
Heart/bronchi/esophagus = 2nd ICS along SB
Upper lung = 3rd ICS along SB
Lower lung = 4th ICS along SB
Neurologic OMM considerations for PNA pt include chapman’s points, somatic nervous system, and autonomic nervous system.
What are the somatic nervous system components that could be addressed?
Cranial considerations — dural tension, tension around jugular foramen — relieve vagus
Paraspinal tension reflecting general neurologic tone in the cervical area
Neurologic OMM considerations for PNA pt include chapman’s points, somatic nervous system, and autonomic nervous system.
General ANS can be addressed with CV4. Increased parasympathetic tone may lead to thickening of secretions and relative bronchiole constriction. What are the parasympathetics that could be addressed?
Vagus n. — OA, AA, C2
Tenderpoints
Compression of OM sutures as well as OA joint
Neurologic OMM considerations for PNA pt include chapman’s points, somatic nervous system, and autonomic nervous system.
Increased sympathetic tone may lead to bronchiole dilation. What are the sympathetics and motor components that can be addresseed?
Sympathetics: T1-7; direct inhibition; Tender points; Gentle rib raising
Motor: C3-5 (phrenic n. to the diaphragm; irritation caused by decreased excursion and overuse; tenderpoints
Met-En-Immune considerations for OMM in PNA pt
OMT using lymphatic pumps has been shown to increase circulating leukocytes reflecting an enhancement of immune response
Behavioral OMT considerations for PNA pt
Maintain hydration
Nutritious diet
Reassurance — palpation and dx of SDs relieves pt stress
Neurologic OMM considerations for PNA pt include chapman’s points, somatic nervous system, and autonomic nervous system.
What are the posterior chapmans points associated with bronchi/esophagus, upper lung, and lower lung?
Bronchi/esophagus = lateral to T2 SP
Upper lung = intertransverse spaces between T2-3 AND T3-4
Lower lung = intertransverse space between T4-5
What nerves are being tested by biceps, brachioradialis, and triceps reflexes?
Biceps — tests primarily C5 (with some C6)
Brachioradialis — tests primarily C6 (with some C5)
Triceps — tests primarily C7 (with some C8)
Describe cervical compression test
Doc applies axial compression of head in neutral
Positive test = pain down arm in nerve root distribution
Indicates nerve root compression (cervical radiculopathy)
Describe spurling’s maneuver
3 stages — if symptoms are produced at any of which, the test is positive and there is no need to proceed to next stage
- Compression of head in neutral
- Compression of head in extension
- Sidebend away from affected side then toward the affected side and add compression
Positive = pain down arm in nerve root distribution — indicates cervical radiculopathy
ROM of cervical spine in rotation, SB, flexion, and extension
Rotation = 70-90
SB = 20-45
F = 45-90
E = 45-90
Describe the oculocephalogyric reflex
When pt is asked to make specific eye movements, certain cervical and truncal muscles contract and reflexively relaxes antagonist muscles
Technique is most useful in very severe, acute cervical and upper body conditions when other techniques are impossible due to severity of pain, muscle spasm, or strain
[Contraindicated with fracture, dislocation, or severe joint instability at treatment site]
Ex: extension SD - pt looks toward feet, flexion SD - pt looks up, R SB SD - pt looks up and to left (induces SB L), etc.
Contraction of what muscles elevates ribs 1 and 2?
Rib 1 = Anterior and middle scalenes
Rib 2 = Posterior scalenes
[“woke up at 1AM 2P”]
Contraction of pectoralis mm can cause ______ rib dysfunction, while engaging pec minor can help treat _____ rib dysfunctions
Anterior(inhalation); exhalation
Accessory muscle of inhalation when scapula is fixed in place (i.e., COPD pt grasping bedrail)
Serratus anterior m.
Describe each rib in terms of bucket handle vs. pump handle vs. caliper motion
Rib 1: 50% pump, 50% bucket
Rib 2: primarily pump
Ribs 3-6: mixed pump handle and bucket motion
Ribs 7-10: primarily bucket
Ribs 11-12: caliper motion
What is scrofula?
Infectious cervical lymphadenitis
Nerve entrapment by musculoskeletal or myofascial tissue that produces paresthesias in the area of distribution of the nerve and creates sensory dysfunction/pain and may also decrease muscle strength. Common sites include intervertebral foramen and the thoracic outlet
Central neuropathy
Describe the neck distraction test
Doc places one hand under pts chin and the other around the occiput, slowly distracting the head
+ test = alleviation of symptoms — indicates central neuropathy
Describe the valsalva test
Pt holds breath and bears down which increases intrathecal pressure
+test = increased symptoms (pain/paresthesia in nerve root distribution) - indicates space occupying lesion in cervical canal
Boundaries of thoracic outlet
1st ribs
1st thoracic vertebra
Manubrium
[contains brachial plexus, subclavian v., subclavian a., thoracic duct (L side)
Describe Roos or EAST test
Abduct shoulder to 90 and ER with elbow flexed to 90. Instruct pt to open and close fist for up to 3 mins
+ test is reproduction of symptoms — indicates TOS, specifically compression of subclavian a
Describe adson test
Locate radial pulse on affected arm; doc abducts, extends, and ER shoulder while palpating radial pulse
First pts head is extended and rotated toward affected side, then extended and rotated away from affected side
+ test = loss or change in pulse, reproduction of symptoms — indicates TOS, specifically compression of subclavian a. between scalenes (when looking away) or 1st rib/cervical rib (when looking toward affected side)
Describe wright’s hyperabduction test
Doc locates and monitors radial pulse on affected side. Abduct the pts arm above head with some extension
+ test = loss or change in pulse, reproduction of symptoms — indicates TOS, specifically neurovascular entrapment by pec minor m.
Describe costoclavicular test (military/halstead test)
Doc locates and monitors radial pulse on affected side. With elbow extended and supinated, extend shoulder and apply caudal pressure to shoulder
+ test = loss or change in pulse, reproduction of symptoms — indicates TOS, specifically neurovascular entrapment between 1st rib and clavicle
What is indicated by a positive kernig sign?
[+ test is marked neck stiffness/resistance to flexion]
Indicates inflammation in subarachnoid space (e.g., meningitis or subarachnoid hemorrhage)
What is indicated by a positive brudzinski sign?
[+ test is flexion in both hips and knees]
Indicates inflammation in subarachnoid space (e.g., meningitis or subarachnoid hemorrhage)
[Kernig sign can also be tested by passively extending leg at the knee and positive test is increased resistance to extension and pain behind the knee, indicating meningeal/dural irritation — but sensitivity and specificity are limited with this method]
Etiology of cervical spinal cord injuries
Can happen in ANY sport, but particularly football, hockey, lacrosse
Axial load accounts for over half of C-spine injuries — force transmitted to bone and disc
Neck flexion to 30 degrees —> lordosis lost and protective soft tissues no longer protective
What is a jefferson fracture?
Axial compression —> C1 fracture
What is a wedge fracture?
Flexion and compression injury to cervical spine
What is a hangman’s fracture?
Hyperextension injury —> C2 bilateral arch fracture
What mechanism of injury leads to fracture of cervical spinous process?
Hyperextension or avulsion force from muscle contraction
What is a clay shoveler’s fracture
C6 or C7 fracture
What is a teardrop fracture?
Flexion and compression injury —> anterior-inferior teardrop fragment
What is a burst fracture?
Comminuted fracture; can result in severe spinal cord injury
What is an anterior subluxation?
Flexion injury — facet dislocation w/o fracture
