Teaching - Week 3 Flashcards
What are the Light’s criteria?
if at least one of the following three criteria is fulfilled, the fluid is defined as an exudate:
Pleural fluid protein/serum protein ratio greater than 0.5,
or
Pleural fluid LDH/serum LDH ratio greater than 0.6,
or
Pleural fluid LDH greater than two-thirds the upper limits of the laboratory’s normal serum LDH
What are the most common causes of transudative pleural effusions?
heart failure, cirrhosis with ascites, and hypoalbuminemia (usually due to the nephrotic syndrome).
What are the most common causes of exudative pleural effusions?
pneumonia, cancer, pulmonary embolism, and tuberculosis
What is the mech of transudative pleural effusion?
some combination of increased hydrostatic pressure and decreased plasma oncotic pressure.
What is the mech of exudative pleural effusion?
increased capillary permeability, leading to leakage of protein, cells, and other serum constituents.
How do you diagnose SLE? (EULAR)
ANA 1:80
Plus, at least one clinical feature
Plus, a point total between clinical and lab features of at least 10 pt
What are the categories in the clinical EULAR criteria for SLE dx?
Constitutional: fever
Hematologic: Leukopenia, thrombocytopenia, autoimmune hemolysis
Neuropsych: delirium, psychosis, seizure
Mucocutaneous: non-scarring alopecia, oral ulcers, subacute cutaneous or discoid lupus, active cutaneous lupus
Serosal: pleural or pericardial effusion, acute pericarditis
MSK: Joint involvement
Renal: Proteinuria >0.5 g per 24 hours, Renal biopsy Class II or V lupus nephritis, Renal biopsy Class III or IV lupus nephritis
What is subacute cutaneous lupus?
Annular or papulosquamous (psoriasiform) cutaneous eruption, usually photodistributed.
What is discoid lupus?
Erythematous-violaceous cutaneous lesions with secondary changes of atrophic scarring, dyspigmentation, often follicular hyperkeratosis/hematological (scalp), leading to scarring alopecia on the scalp.
What is acute cutaneous lupus?
Malar rash or generalized maculopapular rash observed by a clinician.
What is tacrolimus?
Immunosuppressant
Used in heart, kidney, and liver transplant rejection prophylaxis
What are the additional lab/immunological criteria in the EULAR lupus Dx?
Antiphospholipid antibodies: Anti-cardiolipin antibodies or anti-beta-2GP1 antibodies or lupus anticoagulant
Complement proteins:
- Low C3 or low C4
- Low C3 and low C4
SLE-specific antibodies:
Anti-dsDNA antibody or anti-Smith antibody
What is the initial presentation of chronic lymphocytic leukemia?
Often found incidentally on CBC: anemia, thrombocytopenia
Can cause lymphadenopathy (50% have, cervical and supraclavicular most commonly involved though can be generalized)
Can cause hepatosplenomegaly
What is small lymphocytic leukemia?
Same as CLL, but starts in lymph node whereas CLL starts in bone marrow
When do you first suspect CLL?
absolute peripheral lymphocytosis of > 5 × 10^9/L
What is a smudge cell?
CLL cells that get squished on glass slide
What tests are required for Dx of CLL?
Absolute lymphocytosis (> 5 × 10^9/L) and confirmation with flow cytometry
Flow cytometry: confirm clonality in circulating B cells. The circulating lymphocytes should express CD5, CD19, CD20, CD23, and kappa or lambda light chains
Bone marrow biospy not needed
What is the prognosis for CLL?
Varies: <2y to >20y!
Can transform to B cell lymphoma or non-Hodgkin lymphoma
What is the treatment for CLL?
Disease-directed treatment options include
- Chemoimmunotherapy
- Targeted therapy
- Radiation therapy
Supportive care includes
- Transfusion of packed red blood cells for anemia
- Platelet transfusions for bleeding associated with thrombocytopenia
- Antimicrobials for bacterial, fungal, or viral infections
What is a consideration in Abx selection in CLL?
Because neutropenia and hypogammaglobulinemia limit bacterial killing, antibiotic therapy should be bactericidal.
Gamma-globulin infusions should be considered for treatment in patients with hypogammaglobulinemia and refractory infections or for prophylaxis when ≥ 2 severe infections occur within 6 months.
What is hyperviscosity syndrome?
A constellation of symptoms caused by impaired microcirculation of blood as a result of increased blood viscosity; due to increased plasma viscosity
What are the symptoms of hyperviscosity syndrome?
syncope, headache, impaired vision, paraesthesias, and numbness
Can vary specifically with subtype (eg hyperfibrinogenemia more commonly associated with bleeding, polycythemia more commonly associated with CVA and MI, leukemia more commonly associated with small vessel obstruction in lungs and brain)
What are the basic mechanisms/ conditions of hyperviscosity syndrome?
serum viscosity due to hyperfibrinogenemia, hypergammaglobulinemia: often in Waldenstrom or multiple myeloma
whole blood viscosity due to increased RBC: polycythemia vera
whole blood viscosity due to increased WBC: myeloid and monocytic leukemias, with WBC > 100
decreased deformability of cells: sickle cell
What is leukemia?
malignant condition involving the excess production of immature or abnormal leukocytes, which eventually suppresses the production of normal blood cells and results in symptoms related to cytopenias.
Abnormal proliferation, clonal expansion, aberrant differentiation, and diminished apoptosis (programmed cell death) lead to replacement of normal blood elements with malignant cells.
What are the four most common leukemias? (by % of new Dx)
Acute myeloid leukemia (AML): 33% Acute lymphoblastic leukemia (ALL): 10% Chronic myeloid leukemia (CML): 14% Chronic lymphocytic leukemia (CLL): 35% Other leukemias: 8%
How is leukemia commonly categorized?
Acute or chronic: Based on the percentage of blasts or leukemia cells in bone marrow or blood
Myeloid or lymphoid: Based on the predominant lineage of the malignant cells
What are the findings at Dx in ALL? (age, CBC & diff, clinical, others)
Age: childhood
WBC high in 50%, many lymphoblasts
Anemia severe in >90%
Platelets low in >80%
Lymphadenopathy common, splenomegaly in 60%
Other: Without prophylaxis, central nervous system commonly involved
What are the findings at Dx in AML? (age, CBC & diff, clinical, others)
Any age
WBC high in 60%, many myeloblasts
Anemia severe in >90%
Platelets low in >90%
Lymphadenopathy occasional, splenomegaly in 50%
Other:
- Central nervous system rarely involved
- Sometimes Auer rods in myeloblasts
What are the findings at Dx in CLL? (age, CBC & diff, clinical, others)
Middle and old age
WBC high in 98%, small lymphocytes on diff
Mild anemia in about 50%
Platelets low in 20-30%
Lymphadenopathy common, splenomegaly usual and moderate
Other: Occasionally hemolytic anemia and hypogammaglobulinemia
What are the findings at Dx in CML? (age, CBC & diff, clinical, others)
Adulthood
WBC high in 100%, entire myeloid series on diff
Mild anemia in 80%
Platelets high in 60%, low in 10%
Lymphadenopathy uncommon, splenomegaly usual and severe
Other:
- Low leukocyte alkaline phosphatase level
- Philadelphia chromosome–positive in > 90%
What are the findings at Dx in CML? (age, CBC & diff, clinical, others)
Adulthood
WBC high in 100%, entire myeloid series on diff
Mild anemia in 80%
Platelets high in 60%, low in 10%
Lymphadenopathy uncommon, splenomegaly usual and severe
Other:
- Low leukocyte alkaline phosphatase level
- Philadelphia chromosome–positive in > 90%
Meds: what is amlodipine?
AKA Norvasc
CCB, used for HTN and CAD (incl angina)
Meds: what is tacrolimus?
AKA Prograf
Immunosuppressant, used for transplant rejection prophylaxis (heart, liver, kidney)
Meds: what is spironolactone?
Diuretic, potassium-sparing. Aldosterone receptor antagonist
Used in HTN, edema, hyperaldosteronism, HFrEF (note: no evidence for use in HFpEF)
What diuretic combo is often used in cirrhosis pt?
Spironolactone + lasix
Meds: what is amiodarone?
Class III antiarrhythmic: prolongs action potential in stage 3
Used in: Ventricular arrhythmias, malignant ACLS, VF/pulseless VT ACLS, wide complex tachycardia atrial fibrillation
Dosing:
ACLS: 150 or 300mg IV
rate/rhythm control of afib: 100-200mg PO daily
