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
- Vitamin B12 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
- Warm antibody autoimmune hemolytic anemia
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
- bacterial infection. সহজ বাংলা: ব্যাকটেরিয়ার বিরুদ্ধে লড়াই করা শ্বেত রক্তকণিকা।" data-rx-term="neutrophil" data-rx-definition="Neutrophil is a white blood cell important for fighting bacterial infection. সহজ বাংলা: ব্যাকটেরিয়ার বিরুদ্ধে লড়াই করা শ্বেত রক্তকণিকা।">neutrophil count, which may increase infection risk. সহজ বাংলা: নিউট্রোফিল কম থাকা, সংক্রমণের ঝুঁকি বাড়তে পারে।" data-rx-term="neutropenia" data-rx-definition="Neutropenia means low neutrophil count, which may increase infection risk. সহজ বাংলা: নিউট্রোফিল কম থাকা, সংক্রমণের ঝুঁকি বাড়তে পারে।">Neutropenia (decrease in the number of neutrophils)
- Agranulocytosis
- Glanzmann’s thrombasthenia
- platelet count, which can increase bleeding risk. সহজ বাংলা: প্লাটিলেট কম।" data-rx-term="thrombocytopenia" data-rx-definition="Thrombocytopenia means low platelet count, which can increase bleeding risk. সহজ বাংলা: প্লাটিলেট কম।">Thrombocytopenia (decrease in the number of platelets)
- Idiopathic thrombocytopenic purpura (ITP)
- Thrombotic thrombocytopenic purpura (TTP)
- Heparin-induced platelet count, which can increase bleeding risk. সহজ বাংলা: প্লাটিলেট কম।" data-rx-term="thrombocytopenia" data-rx-definition="Thrombocytopenia means low platelet count, which can increase bleeding risk. সহজ বাংলা: প্লাটিলেট কম।">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.
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 (streptococcus, haemophilus) |
| OB | Preterm labor, placental abruptions, SAB |
| Ophthalmology | Acute retinal ischemia, hyphema (with intra-ocular hypertension) |
| Hematology |
|
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
- Thrombocytopenia
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
- Etiology: severe systemic illness/injury
- 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
- Presentation
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
- Anti-platelet
- 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
- Spinal cord compression
- 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)
- Neutropenic fever
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
- Management
- 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.
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: Lung Window
- Rib-based pleural soft tissue masses.
- Large 5.6 x 4.4cm anterior sternal soft-tissue mass.
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
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
