Thanks to Dr. Nicole Mandich for a great presentation on Multiple Myeloma

Learning Points:

— Diagnostic Criteria for multiple myloma

• bone marrow plasma cells>10%
• serum monoclonal protein >3g
• organ dysfunction (CRAB criteria): Hypercalcemia (serum calcium >11.5 mg/dl [2.88 mmol/liter]), Renal insufficiency (serum creatinine >2 mg/dl), Anemia (hemoglobin <10 g/dl or >2 g/dl below the lower limit of the normal range) and Bone disease (lytic lesions, severe osteopenia, or pathologic fracture)

—  Workup includes:

• chem 10, CBC
• SPEP, UPEP, SPIF, UPIF
• bone marrow aspiration and biopsy
• Serum albumin, LDH, beta-2 microglobulin, CRP
• Metastatic bone survey: skeletal survey + PET, low dose whole body CT, MRI spine/pelvis

— Enjoy this great review article on Multiple Myeloma for more details

Thanks to Dr. Nandita Sriram for presenting an interesting case of atypical metastatic colorectal cancer to bone and lung.

Learning Points:

– Colorectal cancer most commonly metastasizes to lung and liver, but may also metastasize to bone. When this occurs, it often presents as a mixed osteoblastic and osteolytic lesion on imaging.

– Follow up of treated colorectal cancer involves serial CEA measurements (q3-6 months for 2-3 years), annual CT of C/A/P for 3 years, and surveillance colonoscopies at year 1, year 3, then q5 years.

– Appropriate surveillance may drastically improve mortality rates of recurrent cancers, as seen in this link to the NCI’s Surveillance, Epidemiology, and End Result (SEER) program: SEER

Thanks to Dr. Tracy Lin for an excellend case of newly diagnosed HIV presenting as PCP Pneumonia!

Learning Points:

-HIV often presents with opportunistic infections, including PCP pneumonia. PCP pneumonia in an HIV positive patient typically takes an indolent course with weeks to months dyspnea on exertion, fever, and dry cough. PCP pneumonia presents as a more acute and severe infection in immunocompetent patients.

-Findings suggestive of PCP pneumonia include and elevated LDH, diffuse interstitial infiltrates on CXR and patchy GGO on CT. Definitive diagnosis requires a bronchoscopy or BAL with staining or DFA.

– Click Here to read a Cochrane Review describing indications for corticosteroids in addition to Bactrim in severe cases of PCP Pneumonia.

Thanks to Dr. Duminda Suraweera for an excellent review of UGIB management

Learning points:
• Triage:
– SDU vs ICU depending on etiology of upper GI bleed, BP, HR, mental status, ability to protect airway and continued active bleeding
• Immediate interventions:
– Resuscitate, resuscitate AND resuscitate with IVFs
– Transfuse pRBCs to keep Hg>7 as per guidelines published in NEJM
– Transfuse FFP and give vitamin K to reverse coagulopathy and maintain INR<1.5
– Transfuse platelets to keep levels >50K
– Start PPI gtt vs intermittent PPI therapy to promote platelet aggregation and clot formation
– Start Octreotide gtt to decrease portal hypertension via vasoconstriction of splanchnic circulation
– Start short course of Ceftriaxone or Norfloxacin in cirrhotic patients with UGIB in an effort to decrease risk of SBP

Click on this great review article for more learning on variceal hemorrhage

Thank you Dr. Caspian Oliai for a great case of symptomatic pulmonary hypertension!

Teaching Points:

–Classification by the World Health Organization (WHO):

• Group 1 – PAH
• Group 2 – PH due to left heart disease
• Group 3 – PH due to chronic lung disease and/or hypoxemia
• Group 4 – Chronic thromboembolic pulmonary hypertension (CTEPH)
• Group 5 – PH due to unclear multifactorial mechanisms

–EKG clues of right ventricular strain: RVH, RAD, S1Q3T3 pattern, atrial arrhythmias, new incomplete RBBB, ST-segment changes and T-wave inversions in the right precordial leads (V1-3) ; repolarization abnormalities

–Patients’ fluid status can be tenuous, and much caution should be taken when administering fluids and/or diuretics

Great AM report by Dr. Liza Buchbinder! Today we presented a patient who was found to have an anterior mediastinal mass and multiple cavitary pulmonary lesions.

Learning points:

• There is a broad differential for multiple pulmonary nodules, which may be narrowed based on CT characteristics.
• When describing lung lesions on imaging, consider the following characteristics:
  • Pattern: reticular, nodular, or reticulonodular
  • Density of lesions: hypodense (COPD vs. cysts) vs. hyperdense (ground-glass vs. airspace consolidation)
  • Distribution: Central vs. peripheral, upper vs. lower
  • Relationship to secondary lobule: Are lesions perilymphatic, centrilobular, or random?
• A nice primer on reading CTs
• Specifically for cavitary lung lesions, consider:
  • Infection: bacterial abscess, fungal disease (mycobacterial, cocci, histo), septic emboli
  • Malignancy:  lymphoproliferative, SCC, angiosarcoma, Kaposi’s Sarcoma
  • Collagen vascular disease: GPA.

Have a great weekend and continue the great work!

Thank you Dr. Duminda Suraweera for a great and unique case and presentation of GPA presenting as subacute limb ischemia.
 
Learning points:
–Vasculitides are commonly classified by vessel size (small, medium, large). The diagram below is also a great visual way to think about working up vasculitis when it is suspected
–Common clinical presentations of GPA include constitutional symptoms, and disorders of the upper and lower respiratory tract (e.g., sinusitis, hemoptysis) and renal disease (e.g.,glomerulonephritis).
–Click here for a great article on the most recent literature on systemic vasculitides

Thanks to Dr. Diana Sarkisyan for an outstanding case and presentation of likely NMO presenting as acute persistent vision loss.

Learning Points:

– Etiology of acute persistent vision loss can be divided into three broad categories: problems involving the media (keratitis, uveitis, vitreous hemorrhage), retina (CRAO, CVAO, retinal detachment) or optic nerve (ischemia, optic neuritis, or NMO).

-Neuromyelitis optica is an inflammatory disorder of the optic nerves and spinal cord which is distinct from optic neuritis. Diagnosis is made by MRI of brain and spine and seropositivity for NMO-IgG. Treatment includes high dose IV steroids and plasmapheresis for refractory cases.

– Click here for an article describing conditions requiring an emergent ophthalmologic consultation.