Internal Medicine Cases

On physical examination, there was significant point tenderness in L1-L3 vertebrae. No other skin or muscle abnormalities were detected. Lower extremities forces were intact without any weakness.
Suddenly one of the students noticed an abnormal bulging near the manubrium of the sternum which was warm and had erythema and also tender.

Case number 29
A 50 y/o man came to the emergency ward with the chief complaint of low back pain. The pain started 2 months ago and suddenly exacerbated 3 days prior to his admission.
He described it very severe and can not even change his position due to severe pain.
He mentioned significant weight loss and episodic fever and chills.

His vital signs at the beginning
BP 130/80
PR 100/min
SPO2 90%
T 37.3

A few moments later the monitor showed blood pressure rise to 200/120. The patient became dyspneic. The ECG is shown in the picture.

The patient coagulation panel is shown in the picture.
After receiving factor, brain CT scan was done which showed bleeding in the right ocipitotemporal area.
Neurosurgery consult was ordered.

In hemophilia A patients with suspected severe or life-threatening bleeding it is important to "Treat first, evaluate second, plan further therapy third"
For potentially serious or life-threatening bleeding, give factor before imaging or other evaluations.
Initial examination findings may be subtle or absent; treat based on the medical history.
If a diagnostic procedure is required (lumbar puncture, arterial blood gas, arthrocentesis), give factor to raise the level to 100% before performing the procedure.
If the patient requires transfer to another facility, give factor before (or during) transport.
For severe disease, assume the factor level is 0%.
Do not waste factor (administer excess rather than discarding).
Use an indwelling central catheter to administer factor if present. If not, the most experienced individuals should perform venipunctures and place an intravenous line if needed. Traumatic venipunctures can cause painful hematomas that limit intravenous access.

The treatment of choice in hemophilia A patients is the patient's own factor VIII product or recombinant human factor VIII. If neither is available, give plasma-derived factor VIII.
For severe bleeding in patients without an inhibitor, give factor VIII at 40 to 50 units/kg as soon as possible to produce a factor VIII level of 80 to 100%.

For less-severe joint or muscle bleeding, a target factor VIII level of 40 to 50% may be used, by giving factor VIII at a dose of 20 to 25 units/kg.
For severe bleeding in patients with an inhibitor, a bypassing product may be indicated (rFVIIa or FEIBA).

For individuals with mild hemophilia A (baseline factor VIII 5 to 50%) who have a documented response to DDAVP and non-life-threatening (or non-limb-threatening) bleeding, DDAVP may be used.

Case number 28
A 33 y/o confused man was brought to the emergency ward by EMS. He does not answer your questions and just moans and complaints about headache.
Initial vital signs:
BP 130/80
PR 100
RR 24
T 37.8
Weight 80 kg
BS 100

Pupils were midsize and reactive to light
No focal neurological deficit was detected at the beginning.
Fundoscopy showed no significant pathology.

While searching the patient's pockets for any evidence and identity cards, you find a badge with the label "hemophilia A".

Case follow up

After 6 sessions of hemodialysis and supportive care, the patient started to urinate about 3-4 liters per day (which was consistent with polyuric phase of ATN). Exessive hydration was prescribed.
Three days after antibiotics administration, he became afebrile and WBC count started to rise.

At the time of discharge he was well oriented and alert.
Urine output was about 2 liters per day. His final lab tests:
Cr 1.1
Urea 67
K 3.8
P 4.4
Ca 9.4
Uric acid 5.4
WBC 5.6
Hb 9.9
Plt 215000

He was then discharged and referred to the hematology clinic.
End of case 27

And about this question

It is important to recognize whether hyperuricemia is secondary to renal failure OR renal failure is due to uric acid nephropathy.

In these cases based on Up-to-date, Overexcretion of uric acid can be documented in many patients by a uric acid-to-creatinine ratio (mg/mg) above 1 on a random urine specimen (although urate nephropathy usually occurs in uric acid levels more than 15 mg/dl).

Another important aspect of the patient is neutropenic fever

Any patient with
✓ one episode of oral temperature > 38.3 °C or
✓ more than one hour with oral temperature > 38°C or
✓ positive SIRS in patients receiving steroids as chemotherapy regimen
AND
Absolute neutrophil count (ANC) (PMN + band cell number) less than 1500

Should be considered as neutropenic fever, which is one of the most important oncologic emergencies.

Early studies of patients with neutropenic fever documented mortality rates of up to 70 percent if initiation of antibiotics was delayed. So we have to start empiric antibiotic therapy within 30 mins of patient admission.

Based on the Up-to-date algorithm for neutropenic fever management, in patients with severe end organ damage (like our patient with renal failure and altered mental status) it is better to use a broad spectrum antibiotic with anti pseudomonas activity (like Meropenem) and a second anti pseudomonas agent (like ciprofloxacin) plus anti MRSA antibiotic (like vancomycin).

However, some references like Harrison 2022 disagrees with the combination antibiotic regimen for gram negative coverage (so if you have chosen Meropenem + vancomycin regimen in the test you are not somehow wrong 😉).

Management of patients who are high risk for tumor lysis syndrome (Harrison 2022)

Case explanation and follow up
Our patient received a chemotherapy agent for a high grade lymphoma malignancy and soon after that he faced anuria, creatinine rise and severe diarrhea.
Our presumption is that bendamustin as the chemotherapy agent caused diarrhea and exacerbated the renal function due to pre-renal azotemia. Hence, do NOT forget tumor lysis syndrome in these patients (laboratory abnormality within 3 days prior and 7 days after chemotherapy).

The patient had hyperuricemia, hyperphosphatemia and more than 25% decrease in serum calcium level (10.8>>7.9)
He had also renal failure (which is clinical sequel for TLS)
So we have to start prophylaxis and treatment for TLS as soon as possible.
As mentioned in the algorithms, hydration and rasburicase are the mainstay treatment of TLS for high risk malignancies.
but (based on Up-to-date) in cases with

●Severe oliguria or anuria

●Intractable fluid overload

●Persistent hyperkalemia

●Hyperphosphatemia-induced symptomatic hypocalcemia

●A calcium-phosphate product ≥70 mg2/dL2

And based on Harrison 2022 in cases with
✓ Serum K+ >6.0 meq/L
✓ Serum uric acid >10 mg/dL
✓ Serum creatinine >10 mg/dL
✓ Serum phosphate >10 mg/dL or
✓ increasing Symptomatic hypocalcemia present

We should start renal replacement therapy (hemodialysis)

So our patient went on hemodialysis for 6 consecutive daily sessions. Adequate hydration and diuretic was resumed.

Uptodate - Tumor lysis syndrome (TLS) prophylaxis recommendations based on TLS risk.pdf

Cairo-Bishop clinical tumor lysis syndrome definition and grading (Up-to-date)

Cairo-Bishop definition of laboratory tumor lysis syndrome

Tumor lysis syndrome risk assessment and prevention algorithm (UP-TO-DATE)