Oncology and Rheumatology Flashcards
Spinal Cord Compression
Most common malignant causes (3)
Most common location
Dx pearl
Tx
–Big three are lung, breast and prostate (combined = 60%)
•60% thoracic, 30% lumbosacral, 10% cervical
CT/MRI (MRI of the whole spine is best)
high-dose steroids, pre-op, maybe radiation
Airway obstruction
Associated Cancers (4)
–Laryngeal CA
–Thyroid CA
–Lymphoma
–Metastatic lung CA
Cancer-Related Pericardial Effusion
Most common cancer types (3)
Other associated causes (3)
- Most common cause is lung / breast cancer
- Malignant melanoma has a special predilection for the heart
–Radiation
–Infection
–Chemotherapy
Pericardial Effusion
classic findings (6)
definition of associated eponym
–Hypotension / narrow pulse pressure
–Jugular venous distention
–Diminished heart sounds
–Pulsus paradoxus greater than 10 mmHg (an exaggeration of the normal physiologic response)
–Low QRS voltage
–Cardiomegaly on x-ray without evidence of CHF
Pulsus paradoxus: abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg.
Superior Vena Cava Syndrome
most common malignant cause
Non-malignant etiologies
–Bronchogenic lung cancer (70%)
–Lymphoma (12%)
Non-malignant causes
–Goiter
–Pericardial constriction
–Thrombosis
–TB
–Radiation
–Central lines
Superior Vena Cava Syndrome
Tx - med(2), proc (2)
Less common sx
Steroids, diuretics, radiation if appropriate, SVC stenting
–ICP increase (may cause syncope [10%])
–Dyspnea (54%), cough (54%), hoarseness (17%)
–Papilledema
–Neck (63%) and upper chest vein congestion (53%)
–Facial plethora / telangiectasia (20%)
–Occasionally a palpable supraclavicular tumor mass
–Enlarged mediastinum on CXR
Cancer-Related Hypercalcemia
Prognosis
Mechanism (2), most common
Most common cancer types (2)
•10-30% of CA patients. Poor prognostic sign – 80% die within a year (median survival = 6 weeks)
Mechanism
–Tumor cells produce PTH-rP (PTH related protein) which mimics hyperparathyroidism ->increased bone resorption and renal calcium retention. This is most common cause (80%) Caused by any solid tumor. Squamous cell lung, breast most common causes.
–Osteolytic metastasis (lung and breast CA most common)
Hypercalcemia relationships
- Calcium and albumin
- Calcium and phosphate
- Calcium and pH
•Calcium and albumin
–Most calcium is bound to albumin
–Low serum albumin = low serum calcium
–Biologically active calcium is the ionized unbound component
•Calcium and phosphate
–Inverse relationship: when one declines the other increases
•Calcium and pH
–Alkalosis causes a decrease in ionized calcium and an increase in bound calcium = functional hypocalcemia
Hypercalcemia
Tx (4)
Hydration with isotonic saline
–Loop diuretics – increase calcium excretion (thiazides decrease calcium excretion)
–Calcitonin (inhibits bone resorption and increases calcium excretion, onset 4-6 hours, duration of action 6-12 hours) / max lowering effect, 1-2mg/dl)
–Bisphosphonates – block osteoclastic bone resorption - takes 1-3 days for effect (pamidronate /zoledronic acid)
Short QT cause
hypercalcemia
Cancer-Related SIADH
Common causes
Mechanism
Associated findings (3)
Tx (3)
- cancer of the brain, lung, pancreas, duodenum, thymus, prostate and lymphosarcoma (think of midline cancers)
- Ectopic secretion of ADH (excess antidiuretic hormone will cause water retention)
- Manifestations
–Hyponatremia / low osmolality / normovolemia
–Less than maximally dilute urine
–Excessive urinary sodium excretion
•Treatment
–Find and eliminate cause
–Fluid restriction
–Hypertonic saline if seizures or cardiac arrhythmias
Cancer-Related Hyperviscosity Syndrome
common causes (3)
etiology (2)
Sx and cause
Tx (3)
- Usual causes - macroglobulinemia, multiple myeloma, CML
- Due to marked increase in serum proteins (usually immune globulins) or WBCs
- Symptoms due to sludging of blood flow and reduced perfusion and microthromboses
- Fatigue, headache, anorexia and somnolence are early findings (sounds a lot like hypercalcemia)
Tx: hydration, phlebotomy and plasmapheresis
These sx might suggest:
–AMS
–Anemia
–Hypercalcemia
–Rouleaux formation on peripheral smear
–“Sausage-linked” retinal vessels on fundus exam
–Factitious hyponatremia
Cancer-Related Hyperviscosity
Syndrome
“Sausage-Linked” Retinal Vessels suggestive of hyerviscosity
Cancer-Related Adrenal Insufficiency
Cause
Precipitants
Sx cluster
Dx pearl
- May occur from tumor that invades adrenals or adrenocortical suppression
- May be precipitated by infection, dehydration, surgery, trauma
- Consider in all cancer patients with fever, dehydration, hypotension and shock
- Empirically treat steroid-dependent cancer pts who have the above findings /get cortisol level before empiric tx
Bottom line: Cancer pt on steroids with sepsis-like picture?
Think adrenal insufficiency!
This suggests:
- Hypoglycemia
- Hyponatremia
- Hyperkalemia
- Eosinophilia
Treatment
Cancer-Related Adrenal Insufficiency
•Patients without adrenal function need about 35-40mg of hydrocortisone per day (250-500mg as an emergency dose to treat adrenal insufficiency crisis)
Tumor Lysis Syndrome
Timing
Most common causes
Labs (4)
Sx
Dx pearl
- 12-72 hrs post treatment
- Blood-based cancers are particularly prone to causing TLS – non-Hodgkins lymphoma, acute or chronic lymphocytic or myelogenous leukemia / breast, testicular, small cell lung
- Release of intracellular electrolytes with elevations of K (the most life-threatening component of TLS), Mg, PO4 and decreases of calcium (from combining with phosphorus and precipitating)
Sx: based on labs abls as above + Extensive DNA / RNA breakdown causes uric acid precipitation in the tubules and acute nephropathy
- LDH elevations indicate extensive cell lysis
- Manifestations – rapid onset and life-threatening
- Dehydration and renal insufficiency predispose
Tumor Lysis Syndrome
Tx (3 categories)
Reduce PO4 – hydration and forced diuresis / oral phosphate binders (aluminum hydroxide) / hemodialysis
Reduce K – hydration, furosemide / aerosolized adrenergics / glucose-insulin infusions / oral potassium binders (sodium polystyrene – works very slowly)
Reduce uric acid: alkalinization of the urine, Allopurinol and Rasburicase
Tumor Lysis Syndrome
Peaked Tws from hyperkalemia, uric acid crystals
Joint Fluid Analysis
First 2 most useful tests
Cell count useful for
glucose low in
•Culture is 1st, gram stain, crystal exam, cell count, glucose
Cell count: inflammatory vs non (eg not a great test for septic vs gout etc)
> 50k typical for SA; < 2000 for non-inflammatory
septic arthritis and RA
Septic Arthritis
most common cause overall and
newborn, children
sexually active adult
sickle cell
SLE
Staph aureus, #2 = Strep
newborn, children: staph, group B strep
sexually active adult: Neisseria gonorrhea, staph
sickle cell: salmonella
SLE: salmonella
Septic arthritis
IVDU location and pathogens
joint prosthesis, pathogen by timing
•IVDU- often involves axial skeleton (ribs, vertebrae, sternoclavicular and SI joints), often Gram negatives & Pseudomonas
–Joint prosthesis – early after surg. = Staph / late = Gram neg
Gout versus pseudo-gout
crystal type
the etiology
locations
who
Gout vs. Pseudogout
crystal shape
x-ray findings
treatment
Gout: needle shaped; pseudogout: rhomboid
X-ray: pseudogout shows calcification of joint cartilages
NSAIDs, colchicine, steroids
for gout allopurinol (decreases uric acid production), probenecid (increases uric acid excretion)
Chondrocalcinosis due to pseudogout
Chondrocalcinosis due to pseudogout
Gonococcal arthritis
epidemiology, timing
characteristic finding
diagnostic and tx pearl
- More common in females (4:1)
- Symptoms often start during menses
- Begins with fever, chills, migratory tenosynovitis, arthritis (knee, ankle, wrist)
- Characteristic rash in 2/3rds - hemorrhagic, necrotic pustules with surrounding erythema (usually occurs first on distal extremities)
- Blood and joint cultures are frequently negative for GC
- Treat empirically in young female patients with fever, migratory polyarthritis and polytendonitis
fever, chills, migratory tenosynovitis, arthritis (knee, ankle, wrist)
young woman
rash
Dx = ?
Gonococcal Arthritis
Antiphospholipid Syndrome
general definition
manifestations
treatment
- A noninflammatory autoimmune syndrome generating antiphospholipid antibodies whose primary pathologic process is thrombosis (both arterial and venous) –occurs mostly in young women (age 30-40)
- Multiple potential manifestations:
–Stroke / MI / retinal vessel thrombosis / PE / placental ischemia and recurring fetal loss
–Responsible for 15-20% of all DVTs under 50 and 1/3 of strokes in this age group
–Catastrophic APL syndrome:
•Sudden, diffuse vascular occlusion leading to multi-organ failure
Tx: lifelong warfarin
Rheumatologic Arthritis Emergencies (3)
Septic arthritis: consider with mono articular flareup
Atlantoaxial subluxation: upper extremity symptoms
–Cricoarytenoid arthritis / symptoms often precipitated by laryngeal manipulation or infection / hoarseness, fullness in the throat or FB sensation / stridor – laryngoscopy can show laryngeal edema, reduced cord motility
Atlantoaxial subluxation
Rheumatologic Arthritis
treatment classes treatment complications (2)
treatment classes (both –DMARDs, disease-modifying anti-rheumatic drugs) :
- conventional (methotrexate) and Biologics (more selective), usually second line due to increased risk of complications
treatment complications: infection and cancer
Rheumatoid factor negative spondyloarthropathies
ankylosing spondylitis features
Factor negative: ankylosing spondylitis, inflammatory bowel disease, psoriasis, reactive arthritis
ankylosing spondylitis features: –Is characterized by sacroiliac arthritis, arthritis and fusion of the spine (“bamboo spine”) / can have atlantoaxial subluxations (like RA) and spine fractures
Reactive arthritis
definition
most common causes (three)
subtype with eponym triad
reactive arthritis (arthritis triggered by an infection
•Reactive arthritis can also be caused by cervicitis and other infections (including Salmonella and Shigella GI infections)
urethritis causing arthritis, conjunctivitis and uveitis = Reiter’s syndrome
In closing spondylitis bamboo spine infusion of spinal processes
Scleroderma
definition
complication and treatment
Definition:–A chronic systemic autoimmune disorder – can be limited to the hands, arms and face or diffuse involving multiple organs
Renal Crisis:
- Usually within 4 yrs of diagnosis
- Steroids implicated in precipitating
- Classic cases – headache, malignant hypertension, elevated creatinine, microangiopathic anemia, thrombocytopenia
- Diagnosis may be missed when malignant hypertension is not present (about 10% of cases)
- Treatment of renal crisis: ACE-I, Immunosuppresants
Raynaud’s disease/phenomenon
phenomenon versus disease
three criteria
attack progression
Raynaud’s “phenomenon” = Raynaud’s disease when there is an underlying cause (scleroderma, RA, SLE)
–Episodes precipitated by cold or emotion
–Symptoms are bilateral
–Symptoms for at least 2 years
–Minimal to no gangrene (skin only if present)
•Attacks are triphasic (white>blue>red)
Raynauds
Systemic Lupus Erythematosus
epidemiology manifestation categories (9) (or spared organ systems)
Tx
•Multi-organ autoimmune disease / most are females (esp. African-Americans), age 16-55 / exacerbations and remissions are typical / runs in families
manifestations: almost every organ system except liver and spleen, full list below
TX: steroids in most cases
- Constitutional symptoms: fever, fatigue, malaise, anorexia
- Rheumatologic: can mimic RA, arthralgias (>90%), myalgias, tenosynovitis
- Dermatologic: butterfly facial rash (55-90%) / intermittent
•Discoid lupus: scaly, raised plaques primarily on face, head, neck; most patients with discoid lupus do not have SLE
- Renal: nephritis (persistent proteinuria), nephrotic syndrome, chronic renal failure
- Cardiac: pericarditis (20-30%), myocarditis, effusions, tamponade
- Pulmonary: pleural effusions, pleurisy, pulmonary infarcts, pneumonitis, cough, dyspnea
- GI: oral & nasal ulcerations, intestinal vasculitis, possible perforation/gangrene
- Hematologic: anemia, thrombocytopenia, auto-splenectomy, thrombosis (often due to antiphospholipid syndrome – can be catastrophic)
- Neurologic: seizures, strokes, psychosis (may be due to SLE or steroid treatment of SLE), migraines, neuropathy (neuro events often occur when SLE is active in other organs), transverse myelitis (due to thrombosis or CNS vasculitis – back pain, extremity neuro symptoms, bladder dysfunction, paralysis – MRI)
Rheumatic Fever
definition
diagnosis
Definition: autoimmune complication of group a beta hemolytic strep infection occurring 3 to 4 weeks after infection
diagnosis: two major or one major and two minor Jones criteria
Jones crieria
for diagnosis of
major (5) criteria
To diagnose rheumatic fever
Major criteria:
–Migratory polyarthritis
–Carditis*
–Chorea* (rapid face and arm movements – late)
–Erythema marginatum*
–Subcutaneous nodules*(back of wrist, elbow, front of knees)
Jones criteria, minor
•Minor criteria
–Fever
–Arthralgias
–Prior history of RF
–Prolonged PR interval
–Elevated acute phase reactants (CRP)
–Evidence of group A strep infection
Rash name and association
Erythema marginatum
major criteria for rheumatic fever
