Heme/onc Flashcards
List red flags associated with lymphadenopathy (6)
Constitutional sx, arthralgias, bruising, petechiae, supraclavicular, large nodes, chronic / non-resolving
List the electrolyte findings seen in tumor lysis syndrome
hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia
Bacterial causes of lymphadenitis, and usual antibiotic choice
GAS or S. aureus (including MRSA)
Treat with Keflex, amox-clav or clindamycin for MRSA for 10-14 days
What is Parinaud (oculoglandular) syndrome
Conjunctivitis and ipsilateral pre-auricular adenopathy
Initial lab work-up of anemia
CBC+diff, reticulocyte count, type and cross, coagulation studies, FOBT, bilirubin, haptoglobin, pregnancy test as indicated
Symptoms and lab findings seen in hemolysis
Symptoms: jaundice, splenomegaly, dark urine, + symptoms of anemia (fatigue, pallor, syncope, shortness of breath)
Labs would show high retic count, dec haptoglobin, inc LDH, unconjugated bili and heme in the urine
Lab work-up of hemolytic anemia
CBC+diff, peripheral blood smear, reticulocyte count, type and cross, antibody screen (indirect Coombs test), DAT, electrolyte, urea/Cr, indirect and direct bilirubin, haptoglobin, LDH
Differential diagnosis of hemolytic anemia
DDx: intrinsic (enzyme, Hg, membrane/) vs. extrinsic
Infections – mycoplasma, EBV, CMV, parvovirus
Toxins/meds – lead, naphthalene , quinidine, rifampin, antibiotics, IVIG
Autoimmune – SLE, thyroiditis
Malignancy- lymphoma
Immune disorders- CVID
Mechanical fragmentation – heart valves, HUS, TTP
Management of autoimmune hemolytic anemia (AIHA)
- Transfuse slowly is symptomatic or severe anemia
- Steroids
- IVIG, Plasmapheresis, splenectomy
List acquired causes of methemoglobinemia
benzocaine, dapsone, chloroquine, nitrates, paraquat, rasbirucase, lidocaine, EMLA, sulfonamide, methylene blue, phenytoin, well-water (high nitrates)
At what level to treat methemoglobinemia, and what is the treatment
Treatment: if > 20% MetHg (or > 10% if underlying cardiopulmonary disease)
- give 1-2 mg/kg of methylene blue (not to give in G6PD)
- Discontinue any offending agents
- ascorbic acid
- Exchange transfusion if failed methylene blue or G6PD
2 causes of pure RBC aplasia
Diamond Blackfan anemia
TEC (transient erythroblastopenia of childhood)
DDx of neutropenia (list 6)
- Differential: congenital/ inherited vs. acquired
- Congenital: cyclic neutropenia, Schwachman-Diamond syndrome, various other syndromes
- Acquired:
- Drugs (anticonvulsants – VPA, antibiotics – penicillins, chemotherapy, radiation, etc.)
- Infectious (viral suppression)
- Bone marrow infiltrate/failure
- Nutritional
- Auto-immune (or neonatal allo-immune NAIT)
Treatment options of ITP
Treatment: Depends on degree of bleeding
o Absent to mild bleeding (petechiae, mild epistaxis): observation (or IVIG or steroids)
o Moderate (more severe skin lesions, non-severe mucosal bleeding – epistaxis, menorrhagia): steroids or IVIG (Rhogam is an option if Rh+, risk of hemolysis)
o Severe (bleeding episodes requiring admission or blood transfusions, Intracranial hemorrhage): steroids, IVIG, platelet transfusion, ?urgent splenectomy
All patients: avoid aspirin, NSAIDs, activities that can cause head trauma
IVIG side effects (list 4)
risk hypersensitivity reaction, headache, aseptic meningitis, fever/chills, hemolysis, hypotension (and ++expensive)
DDx of RUQ abdominal pain in sickle cell disease
- DDX RUQ pain: liver infarction from sickling, cholelithiasis (chronic hemolysis), hepatitis from infectious cause, pancreatitis, peptic ulcer disease and biliary obstruction
Emergency management of priapism in sickle cell
- Oral or IV hydration and pain control
- Pseudoephedrine orally; terbutaline orally or SC (beta-2 receptor agonist)
- Urology consultation if no improvement within 3 hours –> may need aspiration
Low-risk criteria for discharge home in sickle cell patients with fever
> 6 months immunization UTD less than 5% drop in baseline hemoglobin Hg greater 60 g/L stable patients live close to hospital reliable caregiver - cultures + give 1 dose of ceftriaxone in ED, then levofloxacin or azithromycin or clindamycin x 3 days; follow up within 24 hours
Definition of acute chest syndrome
1) new infiltrate on CXR
AND
2) chest pain, fever, cough, tachypnea or hypoxemia
List 6 complications of sickle cell
- Vaso-occlusive crisis
- Acute chest syndrome
- Bacteremia/ sepsis
- Osteomyelitis
- Dactylitis
- Priapism
- Gallstones
- Stroke
- Splenic sequestration
4 conditions that can cause an isolated increase in PTT
hemophilia type A (VIII), hemophilia type B (IX), von Willebrand disease, heparin administration, factor XI deficiency
4 conditions that can cause an isolated increase in INR (PT)
warfarin, factor VII deficiency, early liver disease, early vitamin K deficiency
Labs for work-up of suspected von willebrand disease
INR/PTT initially normal (apart from type 3 which has prolonged INR) vWF antigen (quantity) and ristocetin cofactor (quality or function), factor VIII and blood group (vWF lower with type O)
Management of bleeding in Von Willebrand Disease
DDAVP
TXA
if does not responds to DDAVP- factor VIII-vwF concentration (Humate P)
General steps in managing a transfusion reaction
- Stop the transfusion
- Alert blood bank
- Make sure blood given to correct patient
- Supportive care + specific management depending on the cause
- Investigations (ABO blood type and cross match, DAT, CBC, haptoglobin, urinalysis, creatinine, urea, LDH)
List 3 non life-threatening transfusion reactions
- Allergic transfusion reaction (most common)
- Febrile Non-Hemolytic Transfusion Reaction (diagnosis of exclusion - rule out hemolysis, TRALI, sepsis)
- Delayed hemolytic transfusion reaction
List 5 transfusion reactions that can present with fever
Acute hemolysis, anaphylactic, TRALI, septic, febrile non-hemolytic, delayed hemolytic
What two things, other than recurrent infections/sepsis, would cause you to consider splenic dysfunction? (prev. question)
- Presence of Howell-Jolly bodies in circulating RBCs
- “pitted” erythrocytes and Heinz Bodies
- Mild thrombocytosis and leukocytosis
- Splenomegaly or splenic atrophy/decreased uptake of radioactive RBCs on imaging
- Low immune response to vaccines
- Recurrent Splenic sequestration crises
Acute hemolytic transfusion reaction:
List 4 signs/symptoms, 3 lab tests, 4 steps in management.
Signs/Symptoms: triad of fever, flank pain, and red/brown urine is rare. Chest tightness, hypotension, apnea
Labs: Coombs (DAT), CBC, urine, LDH, haptoglobin, bili
- Stop the transfusion
- ABC, complete VS
- IVF with NS. No dextrose as this worsens the RBC hemolysis. Titrate IVF to UO of 100-200ml/L to prevent oliguric RF
- Vasopressors
Hemophilia/vit k deficiency/DIC - list what the changes are to all of INR/PTT/fibrinogen/plts hematology
Hemophilia: Normal INR, prolonged PTT, N fibrinogen, N platelets
Vit K def: Prolonged INR, N/inc PTT, N fibrinogen, N platelets
DIC: inc INR/PTT, low fibrinogen, low platelets
Common presenting sx of ALL
fever, weight loss/FTT, anorexia, lymphadenopathy, hepatomegaly, splenomegaly, pallor, petechiae, epistaxis, back pain, limp, bone pain, CN palsies, headache, head/neck mass
Emergency work-up of new leukemia diagnosis
Labs: CBC plus differential (blasts, atypical lymphocytes or monocytes), peripheral blood smear (blasts greater 20%), electrolytes including calcium/magnesium/phosphate (TLS), uric acid, renal function (urea, Cr), coagulation studies (INR, PTT), blood group and type, antibody screen, liver function tests and liver enzymes, blood culture if febrile
Imaging: chest xray to assess for mediastinal mass, neuroimaging as needed
Treatment of tumor lysis syndrome
- Hyperhydration
- Allopurinol
- Rasburicase (not in G6PD)
- Treatment of hyperphosphatemia: Aluminum hydroxide
- Alkalinize the urine (not always done, unclear efficacy)
- No calcium replacement unless symptomatic
- Hyperkalemia management
Hyperkalemia management
- stabilize cardiac membranes: Calcium carbonate if severe ECG changes
- shift: Ventolin, Insulin/glucose, bicarb (if acidosis)
- eliminate: Furosemide, Kayexalate
- ECG
Bloodwork findings in HLH
high serum ferritin, cytopenias, hypertriglyceridemia, hypofibrinogenemia, transaminitis
List 4 tumors in the anterior mediastinum
4 T’s: terrible lymphoma, thymoma, thyroid carcinoma, teratoma
List 4 complications of mediastinal masses
- SVC syndrome (plethora, facial edema, jugular venous distension)
- Tracheal obstruction
- Tumor lysis syndrome
- Pleural or pericardial effusion
common xray findings of bone tumors
Xray signs: periosteal elevation (codman triangle), sunburst pattern, lytic lesions,
- Osteosarcoma: metaphyseal end of long bones (often the knee) –> “sunburst pattern”
- Ewing sarcoma: diaphysis, ribs –> “Onion skin”
