Hematology/Myeloma/Oncology; Types, Evaluation, Treatment

Hematology
Sending
User Review
5 (3 votes)
Hematology/ haematology is the branch of medicine concerned with the study of the cause, prognosis, treatment, and prevention of diseases related to blood. It involves treating diseases that affect the production of blood and its components, such as blood cells, hemoglobin, blood proteins, bone marrow, platelets, blood vessels, spleen, and the mechanism of coagulation. Such diseases might include hemophilia, blood clots, other bleeding disorders and blood cancers such as leukemia, multiple myeloma, and lymphoma. The laboratory work that goes into the study of blood is frequently performed by a medical technologist or medical laboratory scientist. Many hematologists work as hematologist-oncologists, also providing medical treatment for all types of cancer. The term is from the Greek αἷμα, haima meaning “blood,” and -λoγία meaning study.

Types of Hematology

Myeloid

Hemoglobinopathies (congenital abnormality of the hemoglobin molecule or of the rate of hemoglobin synthesis)

  • Sickle-cell disease
  • Thalassemia
  • Methemoglobinemia

Anemias (lack of red blood cells or hemoglobin)

  • Iron deficiency anemia
  • Megaloblastic anemia
    • Vitamin B12 deficiency
      • Pernicious anemia
    • Folate deficiency

Hemolytic anemias (destruction of red blood cells)

  • Genetic disorders of RBC membrane
    • Hereditary spherocytosis
    • Hereditary elliptocytosis
    • Congenital dyserythropoietic anemia
  • Genetic disorders of RBC metabolism
    • Glucose-6-phosphate dehydrogenase deficiency (G6PD)
    • Pyruvate kinase deficiency

Immune mediated hemolytic anemia (direct Coombs test is positive)

  • Autoimmune hemolytic anemia
    • Warm antibody autoimmune hemolytic anemia
      • Idiopathic
      • Systemic lupus erythematosus (SLE)
      • Evans’ syndrome (antiplatelet antibodies and hemolytic antibodies)
    • Cold autoimmune hemolytic anemia
      • Cold agglutinin disease
      • Paroxysmal cold hemoglobinuria (rare)
      • Infectious mononucleosis

Alloimmune hemolytic anemia

  • Hemolytic disease of the newborn (HDN)
    • Rh disease (Rh D)
    • ABO hemolytic disease of the newborn
    • Anti-Kell hemolytic disease of the newborn
    • Rhesus c hemolytic disease of the newborn
    • Rhesus E hemolytic disease of the newborn
    • Other blood group incompatibility (RhC, Rhe, Kid, Duffy, MN, P and others)
  • Drug induced immune mediated hemolytic anemia
    • Penicillin (high dose)
    • Methyldopa
  • Hemoglobinopathies (where these is an unstable or crystalline hemoglobin)
  • Paroxysmal nocturnal hemoglobinuria (rare acquired clonal disorder of red blood cell surface proteins)
  • Direct physical damage to RBCs
    • Microangiopathic hemolytic anemia
    • Secondary to artificial heart valve(s)
  • Aplastic anemia
    • Fanconi anemia
    • Diamond-Blackfan anemia (inherited pure red cell aplasia)
    • Acquired pure red cell aplasia

Decreased numbers of cells

  • Myelodysplastic syndrome
  • Myelofibrosis
  • Neutropenia (decrease in the number of neutrophils)
  • Agranulocytosis
  • Glanzmann’s thrombasthenia
  • Thrombocytopenia (decrease in the number of platelets)
    • Idiopathic thrombocytopenic purpura (ITP)
    • Thrombotic thrombocytopenic purpura (TTP)
    • Heparin-induced thrombocytopenia (HIT)

Myeloproliferative disorders (Increased numbers of cells)

  • Polycythemia vera (increase in the number of cells in general)
  • Erythrocytosis (increase in the number of red blood cells)
  • Leukocytosis (increase in the number of white blood cells)
  • Thrombocytosis (increase in the number of platelets)
  • Myeloproliferative disorder

Coagulopathies (disorders of bleeding and coagulation)

  • Thrombocytosis
  • Recurrent thrombosis
  • Disseminated intravascular coagulation
  • Disorders of clotting proteins

Hemophilia

  • Hemophilia A
  • Hemophilia B (also known as Christmas disease)
  • Hemophilia C
  • Von Willebrand disease
  • Disseminated intravascular coagulation
  • Protein S deficiency
  • Antiphospholipid syndrome

Disorders of platelets

  • Thrombocytopenia
  • Glanzmann’s thrombasthenia
  • Wiskott-Aldrich syndrome

Hematological malignancies

Hematological malignancies

  • Lymphomas
    • Hodgkin’s disease
    • Non-Hodgkin’s lymphoma {includes the next five entries}
      • Burkitt’s lymphoma
      • Anaplastic large cell lymphoma
      • Splenic marginal zone lymphoma
      • Hepatosplenic T-cell lymphoma
      • Angioimmunoblastic T-cell lymphoma (AILT)
  • Myelomas
    • Multiple myeloma
    • Waldenström macroglobulinemia
    • Plasmacytoma

Leukemias increased WBC

  • Acute lymphocytic leukemia (ALL)
  • Chronic lymphocytic leukemia (CLL){now included in theCLL/SCLL type NHL}
  • Acute myelogenous leukemia (AML)
  • Chronic Idiopathic Myelofibrosis (MF)
  • Chronic myelogenous leukemia (CML)
  • T-cell prolymphocytic leukemia (T-PLL)
  • B-cell prolymphocytic leukemia (B-PLL)
  • Chronic neutrophilic leukemia (CNL)
  • Hairy cell leukemia (HCL)
  • T-cell large granular lymphocyte leukemia (T-LGL)
  • Aggressive NK-cell leukemia

Miscellaneous

  • Hemochromatosis
  • Asplenia
  • Hypersplenism
    • Gaucher’s disease
  • Monoclonal gammopathy of undetermined significance
  • Hemophagocytic lymphohistiocytosis
  • Tempi syndrome

Hematological changes secondary to non-hematological disorders

  • Anemia of chronic disease
  • Infectious mononucleosis
  • AIDS
  • Malaria
  • Leishmaniasis

Blood

  • Venous blood
  • Venipuncture
  • Hematopoiesis
  • Blood tests
  • Cord blood

Red blood cells

  • Erythropoiesis
  • Erythropoietin
  • Iron metabolism
  • Hemoglobin
  • Glycolysis
  • Pentose phosphate pathway
  • White blood cells
  • Platelets
  • Reticuloendothelial system
    • Bone marrow
    • Spleen
    • Liver

Lymphatic system

Blood transfusion

  • Blood plasma
  • Blood bank
  • Blood donors
  • Blood groups

Hemostasis

  • Coagulation
  • Vitamin K
  • Complement system
  • Immunoglobulins

(abnormality of the hemoglobin molecule or of the rate of hemoglobin synthesis)

  • Anemias (lack of red blood cells or hemoglobin)
  • Hematological malignancies
  • Coagulopathies (disorders of bleeding and coagulation)
  • Sickle Cell Anemia
  • Thalassemia

Evaluation

A 27 year-old male with sickle cell disease (HbSC) on hydroxurea and with a history of 2-3 hospitalizations per year for vaso-occlusive pain crises manifested by arthralgias and back pain presents to the emergency department with 3 days of worsening joint pain affecting his entire body but predominantly his knees and lower back. He is familiar with this pain and attempted therapy at home with ibuprofen, then hydrocodone-acetaminophen, and finally hydromorphone without improvement and presented to the emergency department.

You Can Also Like   Water on the Knee; Causes, Symptom, Diagnosis, Treatment

On review of systems, he denied chest pain, cough, or shortness of breath. He has some periumbilical abdominal pain but tolerated normal oral intake on the day of presentation without vomiting nor changes in bowel habits. He otherwise denied fevers, peripheral numbness/weakness, urinary or fecal incontinence or retention. He similarly denies trauma, weight loss, night sweats, or intravenous drug use.

Objectively, the patient’s vital signs were normal and he was well-appearing. Mucous membranes were moist and skin turgor was normal. There were no appreciable joint effusions, warmth, nor limitation to active/passive range of motion of any joints. His back had no midline tenderness to palpation or percussion, normal range of motion in all axes and extremity sensation and strength testing were normal. Abdominal and genitourinary examinations were normal. The patient had preserved perineal sensation to light touch and normal rectal tone – a core temperature was obtained which was also normal.

Peripheral access was established and a parenteral dose of hydromorphone equivalent to his home oral dose was administered (0.015mg/kg). Repeat dosing was required at 15 minutes due to persistent pain scale of 10. Diphenhydramine and acetaminophen were also administered, for potential opioid-sparing effects, recognizing the limited evidence to support these relatively benign adjuncts.

Laboratory studies were notable for anemia (though stable compared to baseline measures), appropriate reticulocyte count, no evidence of hemolysis and with normal electrolytes and renal function.

A thorough history and examination did not identify a critical precipitant for the patient’s symptoms which were presumed to be secondary to a vaso-occlusive pain crisis. On reassessment, the patient’s pain was improved and an oral dose of hydromorphone was administered with continued observation and serial reassessments for two hours thereafter. The patient’s hematologist was available for follow-up the subsequent morning and the patient was discharged home.

Pharmacokinetics of Commonly-Used Opiate Analgesics

MEDICATION ROUTE ONSET PEAK DURATION
Morphine IV 5-10min 20min 3-5h
IM 15-30min 30-60min
PO 30min 1h
Oxycodone PO 10-15min 30-60min 3-6h
Hydrocodone PO 10-20min 4-8h
Fentanyl IV <1min 2-5min 30-60min
Hydromorphone IV 5min 10-20min 3-4h
PO 15-30min 30-60min
Codeine PO 30-60min 60-90min 4-6h

 

Algorithm for the Evaluation and Management of Sickle Cell Crises

Hematologic Emergencies ,Sickle Cell Crises

  • Triggers: infection, acidosis, dehydration, cold-exposure, hypoxia, pregnancy
  • Presentation: exclude alternative more serious pathology prior to ascribing pain to vaso-occlusive crisis

Effects by Organ System

SYSTEM SYMPTOM
CNS Focal or generalized neurological symptoms, stroke, seizure
Pulmonary Acute chest syndrome (fever, chest pain, cough, hypoxia, pulmonary infiltrates), pulmonary embolism
GI Abdominal pain, nausea/vomiting
Renal Papillary necrosis
GU Priapism, testicular/ovarian ischemia
Muskuloskeletal Bone pain (back, proximal extremities), exclude osteomyelitis, avascular necrosis
ID Infection, functional asplenia (streptococcushaemophilus)
OB Preterm labor, placental abruptions, SAB
Ophthalmology Acute retinal ischemia, hyphema (with intra-ocular hypertension)
Hematology
  • Sequestration crisis: acute anemia, often post-viral
  • Hemolytic crisis: acute anemia, reticulocytosis, hyperbilirubinemia
  • Megaloblastic crisis: folate deficiency
  • Aplastic crisis: inadequate reticulocytosis

Evaluation

  • CBC with reticulocyte count
    •  Hemoglobin: suggests sequestration or hemolytic crisis
    •  Reticulocyte index: suggests aplastic or megaloblastic crisis
  • LDH/haptoglobin: evaluate for hemolysis
  • UA: evaluate for infection/infarction
  • CXR: evaluate for acute chest syndrome

Management

  • Rehydration (hypotonic fluids)
  • Analgesia
  • Supplemental oxygen if hypoxic
  • Exchange transfusion for priapism, neurologic symptoms, aplastic/sequestration/hemolytic crises

Transfusion Reactions

  • Epidemiology: overall 0.25%, 0.09% severe
  • Management: stop transfusion

Management by Presumed Etiology

REACTION MECHANISM SIGNS/SYMPTOMS MANAGEMENT
ACUTE, SEVERE
Acute hemolysis Incompatibility Fevers,  HR,  BP, vomiting, back pain IVF, vasopressors if needed, furosemide
Anaphylaxis IgA-mediated  1min: flushing laryngospasm, bronchospasm,  BP Epinephrine, steroids, diphenhydramine, IVF
Sepsis Bacterial contamination (Y. entercolitica), increased risk in platelet transfusion Fevers,  BP IVF, vasopressors if needed, broad-spectrum antibiotics
TRALI (transfusion-related acute lung injury) Non-cardiogenic pulmonary edema, increased risk in FFP transfusion Hypoxia, respiratory distress, XR bilateral infiltrates Supplemental oxygen, PPV/ETT
TACO (transfusion-associated circulatory overload) Hypervolemia in patients with history of CHF Hypoxia, respiratory distress, heart failure Supplemental oxygen, PPV/ETT, furosemide
ACUTE, MINOR
Simple febrile reaction Cytokine-mediated Isolated fever Acetaminophen
Minor allergic reaction Response to transfused plasma proteins Urticaria, pruritus, flushing Diphenhydramine
DELAYED
Delayed hemolysis Minor RBC antigens 5-10d, low-grade hemolysis
GVHD Immunocompromised host Fever, rash, N/V, transaminitis, pancytopenia
MASSIVE TRANSFUSION
Massive transfusion Large-volume, refrigerated products Coagulopathy, hypothermia, hypocalcemia, hyperkalemia, lactic acidosis

Bleeding Disorders

Overview

  • Disorders of primary hemostasis
    • General: present with mucocutaneous, post-operative bleeding
    • vWD
    • Platelet disorders
      • Medication-induced: NSAID, valproate, B-lactam, SSRI
      • Systemic disease: hepatic, renal failure
    • ITP: antibody-mediated platelet destruction
  • Disorders of secondary hemostasis
    • General: present with bleeding into soft-tissue, joints
    • Hemophilia A (VIII)
    • Hemophilia B (IX)
  • Disorders of both primary and secondary hemostasis
    • DIC
    • Liver disease
    • Severe vWD
  • Evaluation
    •  PT: VII, vitamin K
    •  PTT: VIII, IX, XI, XIII, vWD, heparin
    •  Increased PT/PTT: XI, V, vitamin K, heparin, DIC
    • CBC: degree of anemia, platelet count, differential (hematopoetic disorders)
  • Management
    • Thrombocytopenia
      • Prophylactic transfusion for avoidance of spontaneous hemorrhage for platelet count <10,000
      • Transfusion for active bleeding at platelet count <50,000
      • Dosing
        • Adults: one RDP increases platelet count by 7-10,000
        • Pediatrics: 5-10ml/kg
      • ITP
        • Transfuse platelets for active bleeding
        • High-dose steroids (prednisone 1mg/kg)
        • IVIG (1g/kg/d)
      • Uremia
        • Hemodialysis
        • DDAVP (0.3ug/kg IV)
      • vWD
        • DDAVP (0.3ug/kg IV)
        • Severe: VWF (Humate-P) 40-80IU/kg
        • Tranexamic acid
      • Hemophilia A
        • Minor: 20IU/kg
        • Major: 50IU/kg
      • Hemophilia B
        • Minor: 40IU/kg
        • Major: 100IU/kg
You Can Also Like   RTIs; Causes, Symptoms, Diagnosis, Treatment

DIC/TTP/HUS

  • Disseminated Intravascular Coagulation
    • Etiology: severe systemic illness/injury
      • Trauma, burn, crush
      • Sepsis
      • Malignancy
      • Obstetric complication: abruption, amniotic fluid embolism
      • Hemolytic anemia
    • Exam: petechiae/purpura, hemorrhage (puncture site, GI, GU, pulmonary)
    • Labs:
      • PT/PTT 
      • Fibrinogen 
      • CBC: schistocytes, thrombocytopenia
      • FDP/D-Dimer 
    • Management
      • Treat underlying illness
      • Transfuse (PRBC, FFP for INR > 2, cryoprecipitate for fibrinogen < 100)
      • Heparin if apparent embolic events
      • Consult hematology
  • TTP/HUS
    • Presentation
      • Thrombocytopenia
      • Altered mental status
      • Renal dysfunction
      • Fever
      • MAHA
    • TTP: more commonly associated with altered mental status
      • Etiology: drugs, pregnancy, infection (HIV)
      • Mechanism: ULvWF uncleaved by dysfunctional ADAMTS-13
    • HUS: more commonly associated with renal dysfunction
      • Mechanism: toxin from E. coli, Shigella
      • Timing: 1-2wks after diarrheal illness
    • Evaluation
      • CBC: anemia, schistocytes, thrombocytopenia
      • PT/PTT (normal)
      • BUN/Creatinine 
      • LDH 
    • Management
      • Platelets contraindicated except as stopgap measure in ICH (can worsen process)
      • Plasma exchange with FFP (replaces functional ADAMTS-13)
      • Steroids (prednisone 1mg/kg daily)
      • Hematology consultation

Complications of anti-thrombotic therapy

  • Agents
    • Anti-platelet
      • TXA: Aspirin
      • ADP: clopidogrel, ticagrelor, prasugrel
      • GPIIb/IIIa: abciximab, eptifibatide, tirofiban
    • Anti-coagulants
      • Anti-thrombin: heparin, LMWH (enoxaparin, dalteparin)
      • Vitamin K antagonist: warfarn (anti-II, VII, IX, X)
      • Direct thrombin inhibitor: bivalirudin, argatroban, dabigatran
      • Xa inhibitor: rivaroxaban, apixaban
    • Fibrinolytics
      • Alteplase, tenectaplase
  • Complications
    • HIT: platelet count decrease >50% at 5 days

Summary of Management

AGENT REVERSAL
Aspirin, clopidogrel 5-10U plateletsDDAVP 0.3ug/kg
GPIIb/IIIa Abciximab: 5-10U plateletsEptifibatide/tirofiban: none
Heparin Protamine 1mg/100mg heparin in last 2-3 hours
LMWH Enoxaparin: 1mg/1mgDalteparin: 1mg/100U
Warfarin See supratherapeutic INR algorithm
DTI Dabigatran: Praxbind, hemodialysis, consider Factor VIIa
Xa PCC
Fibrinolytics 10U cryoprecipitate, 2U FFP, consider platelets and aminocaproic acid (4-5g IV)

Oncologic Emergencies

  •  Complications
    • Airway obstruction
    • PNA
    • Pleural effusion
    • Pericardial effusion
    • VTE
    • SVC syndrome
      • Symptoms: dyspnea (airway edema), chest fullness, blurred vision, headache (increased ICP)
    • Massive hemoptysis
      • Management: ETT (large-bore for bronschoscopy), affected side down
  • Brain Metastases
    • Cancers: melanoma, lung, breast, colorectal
    • Management: dexamethasone 10mg IV load, elevated HOB, hypertonic saline or mannitol, prophylactic anti-eplipetics
  • Meningitis
    • Pathogens: Listeria (ampicillin), Cryptococcus (amphotericin)
    • Evaluation: CSF sampling with cytology (diagnose leptomeningeal metastases)

Metabolic Disturbances

  • Hypercalcemia
    • Cancers: MM, RCC, lymphoma, bone metastases (breast, lung, prostate)
    • Mechanism: metastatic destruction, PTH-RP, tumor calcitriol
    • Prognosis: 50% 30-day mortality
    • Symptoms
      • Chronic: anorexia, nausea/vomiting, constipation, fatigue, memory loss
      • Acute: CNS (lethargy, somnolence)
    • Findings
      • Calcium: >13.0mg/dL
      • ECG: QT shortening
    • Treatment
      • Mild: IVF
      • Severe: IVF, loop diuretics, bisophosphanate (pamidronate 90mg IV infused over 4 hours), consider calcitriol, consider hemodialysis if cannot tolerate fluids or unlikely to respond to diuretics
  • Hyponatremia
    • Cancers: lung (small-cell), pancreatic, ovarian, lymphoma, thymoma, CNS
    • Mechanism: SIADH
    • Symptoms: muscle twitching, seizure, coma
    • Management: fluid restriction, if seizing administer 3% hypertonic saline at 100cc/hr until resolution
  • Hypernatremia
    • Mechanism: decreased intake, increased GI losses from chemotherapy
    • Management: cautious fluid resuscitation
  • Tumor Lysis Syndrome (TLS)
    • Cancers: hematologic, rapid-growth solid tumors
    • Mechanism: release of intracellular contents (uric acid, K, PO4, Ca)
    • Timing: 1-4 days after therapy (chemo, radiation)
    • Diagnosis
      • Uric acid >8mg/dL
      • Potassium >6mEq/L
      • Calcium <7mg/dL
      • PO4 >4.5mg/dL
      • Acute kidney injury
    • Management
      • IVF, allopurinol, rasburicase, urinary alkalinization
      • Consider hemodialysis if volume overloaded

Localized Complications

  • Musculoskeletal Complications
    • Spinal cord compression
      • Cancers: prostate, breast, lung, RCC, non-Hodgkin lymphoma, MM (5-10% of all cancer patients)
      • Sites: thoracic (60%), lumbosacral (30%), cervical (10%)
      • Symptoms: pain (worse lying flat, cough/sneeze, heavy lifting)
      • Evaluation: MRI (se 93%, sp 97%)
      • Management: dexamethasone 10mg IV load, 4mg q6h, neurosurgical consultation, radiation oncology consultation
    • Pathologic fracture
      • Features: sudden onset, low-force mechanism
  • Therapy Complications
    • Neutropenic fever
      • Definition: ANC <500 or ANC <1000 with expected nadir <500 (nadir typically occurs 5-10d after chemotherapy) with Tmax >38.3°C or >38.0°C for >1h
      • Examination: subtle signs of infection, thorough examination is critical (skin, catheter, perineum)
      • Treatment: carbapenem monotherapy, vancomycin if indwelling catheter, oncology consultation for colony stimulating factors
    • Chemotherapy-induced vomiting
      • Management: ondansetron with dexamethasone, consider NK-1 antagonist (aprepitant)

Hematologic Malignancies

  • Acute leukemia
    • Signs/Symptoms: leukopenia (infection), anemia (weakness/fatigue), thrombocytopenia (bleeding)
    • Diagnosis: >5% blasts
  • Thrombocytopenia
    • Management
      • No bleeding, goal >10,000
      • Fever, coagulopathy, hyperleukoctosis, goal >20,000
      • One unit of platelets increases count by 5,000
  • Hyperleukocytosis
    • Definition: WBC > 50-100k
    • Complications: microvascular congestion (pulmonary, cerebral, coronary)
    • Symptoms
      • CNS: confusion, somnolence, coma
      • Pulmonary: dyspnea, respiratory alkalosis
    • Management: cytoreduction (induction chemotherapy, increased risk TLS)
  • Hyperviscosity
    • Cancer: macroglobulinemia, MM
    • Symptoms: epistaxis, purpura, GIB, neuro deficits
    • Diagnosis: serum viscosity > 1.4-1.8
    • Management: emergent plasmapheresis
  • Polycythemia
    • Diagnosis: Hb >17
    • Differential: dehydration, hypoxia, smoking, altitude
    • Symptoms: HA, vertigo, angina, claudication, pruritus (after showering)
    • Complications: thrombosis (stroke), bleeding
    • Management: emergent phlebotomy (500cc if otherwise healthy)
  • Thrombocytosis
    • Diagnosis: platelet >1,000,000
    • Symptoms: vasomotor (HA, lightheadedness, syncope, chest pain, paresthesias)
    • Management: low-dose aspirin

Anemia

70M with a history of dementia presenting with 3 days of fatigue. The patient was unable to provide detailed history, however family members reported worsening fatigue with the patient requiring assistance with ambulation for several days. The patient was referred from an outside clinic after point-of-care hemoglobin of 6.7. No reported history of anemia, and no history suggestive of obvious external bleeding.

Vital signs stable, tachycardia and tachypnea noted with minimal exertion but saturating well on ambient air and in no acute distress. Examination notable for conjunctival pallor without scleral icterus, systolic flow murmur, brown stool guaiac negative.

You Can Also Like   What can I do to lower my blood pressure immediately?

CBC with hemoglobin of 7.5 , MCV 80.3 , RDW 22.4 , no leukocytosis and normal platelets. Also noted was an alkaline phosphatase of 828 , normal total and direct bilirubin, and undetectable serum troponin. Chest x-ray showed a possible pleural-based mass.

The patient was transfused two units of PRBC’s and admitted for further evaluation. CT chest/abdomen/pelvis revealed sternal and rib-based pleural soft-tissue mass, prostate mass, pelvic and retroperitoneal lymphadenopathy as well as extensive bony metastatic disease consistent with primary prostate cancer with diffused metastasis. Serum PSA was 2,087 . Iron studies suggested anemia of chronic disease. Reticulocytes were not obtained but may have suggested inadequate production index given extensive bony metastases and possible associated myelosuppression. The patient was symptomatically improved after transfusion and discharged with outpatient follow-up for discussions regarding possible biopsy and treatment.

Images

Areas of pleural thickening. Possible pleural based mass in left mid lung.

ct_chest_anemia_01

CT Chest: Lung Window

  • Rib-based pleural soft tissue masses.
  • Large 5.6 x 4.4cm anterior sternal soft-tissue mass.
ct_bone_anemia_01

CT Body: Bone Window

  • Extensive bony metastatic disease.
  • Prostate mass, large pelvic and retroperitoneal lymphadenopathy.
  • Consistent with primary prostate cancer with diffuse metastasis.

Algorithm for the Evaluation of Anemia 

Lymphadenopathy Applied: Lymphoma

27 year-old female with no medical history presenting with neck swelling. She describes one month of progressive enlargement of a left-sided neck mass, and in the past two weeks has noted a new right-sided neck mass. This has been associated with worsening dysphagia to solids, describing a sensation of food lodging in the mid-chest and requiring liquids for passage – she attributes her recent 10lb weight loss to this. She also reports a non-productive cough for the past two weeks and generalized fatigue. She otherwise denies fevers, night sweats, chest pain, shortness of breath, nausea/vomiting, or changes in bowel/urinary habits. She has no known sick contacts or TB exposure risk factors. She has no medical history, no prior surgeries, does not take any medications and denies tobacco, alcohol or drug use.

Physical Exam

VS: T 38.4 HR 98 RR 14 BP 108/68 O2 99% RA
Gen: Well-appearing young female, in no acute distress.
HEENT: PERRL, EOMI, MMM without lesions. There is a 2x3cm firm, non-tender, mobile left supraclavicular lymph node, as well as two 1x1cm firm, non-tender lymph nodes in the left and right anterior cervical chains.
CV: RRR, normal S1/S2, no murmurs. No JVD.
Lungs: Clear to auscultation bilaterally. There is a transition to bronchial breath sounds along the trachea inferior to the sternal angle with normal tracheal sounds superiorly.
Abd: Soft, non-tender without organomegaly.
Ext: Warm and well-perfused with normal peripheral pulses. No axillary or inguinal lymphadenopathy.
Neuro: Alert and oriented, responding appropriately to questions. PERRL, EOMI, facial sensation symmetric, facial muscles symmetric, hearing grossly normal, palate rises symmetrically, tongue movements normal without fasciculation, SCM/trapezius normal. Normal FTN, RAM. Gait intact. Peripheral sensation and motor grossly normal.

Imaging

CT Chest – Axial

Anterior mediastinal mass with a wide differential – likely represents lymphoma or germ cell tumor. Less likely thymic or thyroid origin.

CT Chest – Sagittal

Anterior mediastinal mass with a wide differential – likely represents lymphoma or germ cell tumor. Less likely thymic or thyroid origin.

Assessment/Plan

27F with no PMH presenting with progressive localized lymphadenopathy. Resultant dysphagia, cervical and supraclavicular distribution as well as abnormal tracheal sounds concerning for mediastinal involvement. The patient is currently stable without evidence of airway compromise. ACT of the chest was obtained to evaluate for thoracic malignancy, which showed a large anterior mediastinal mass concerning lymphoma or germ cell tumor. The location of the mass likely explains the patient’s dysphagia due to compression of the esophagus, as well as the abnormal pulmonary exam with compression potentially irritating the trachea and triggering her non-productive cough. The patienthe t was admitted for further workup.

Lymphadenopathy Applied – Lymphoma

This case applies the differential diagnosis of lymphadenopathy. The most abnormal finding on examination was non-tender, left supraclavicular lymphadenopathy. The duration of symptoms and lack of tenderness is concerning for malignancy, and the left supraclavicular location suggests a thoracic or intra-abdominal source.

References

Print Friendly, PDF & Email

Sharing to Spread to the World

Leave a Reply

Your email address will not be published. Required fields are marked *