Suspicious Lymphadenopathy

Pt with h/o HIV presents with new onset lymphadenopathy. Reports fevers, night sweats, unintended weight loss, recent travel, and unprotected sexual contact. Recent exposure to tuberculosis, cats, and ticks. Firm, fixed supraclavicular lymph node > 2 cm in diameter and HSM on exam.

• Labs

  • CBC with manual differential shows cytopenia and lymphoblasts

  • Obtain ESR, CPR, tuberculosis skin titer, Lyme serology, HIV ELISA

  • Consider rapid strep test (GAS), heterophile Ab (EBV), B. henselae serology, anti-neutrophil antibody (Lupus), gonorrhea/chlamydia NAAT, RPR (syphilis)

• CXR shows mediastinal/hilar mass

• Intervention

  • Concerning s/sx: Refer for early lymph node biopsy

  • No concerning s/sx

    • Consider treatment with antibiotics based on index of suspicion

    • Reevaluate in one month and biopsy if no size reduction is observed

• Pt advised to [anticipatory guidance]

Notes

• Concerning features above are in bold

• Presence of HSM suggests disseminated lymphadenopathy

• Refer pediatric patients for biopsy for supraclavicular nodes, multiple nodes > 3 cm, or a single node > 4 cm

• Do not treat with glucocorticoids before establishing a definitive diagnosis

Hodgkin Lymphoma

Pt with h/o immunosuppression including HIV presents with painless lymphadenopathy. Reports cough, night sweats, unintentional weight loss. Family history positive for Hodgkin lymphoma. Low grade fever and painless cervical lymphadenopathy on exam.

• Obtain CXR and chest CT; consider PET scan

• Lymph node biopsy shows Reed-sternberg cells

• Refer to hematology/oncology

• Pt counseled that chemotherapy may result in cardiovascular complications, infertility, and/or premature menopause

• Pt informed that survival rate depends on staging, but is >80% at 5 years overall

• Pt counseled about importance of follow-up as lymphoma recurrence generally happens within a few years after therapy

• Monitoring s/p chemotherapy and radiation

  • Obtain CXR at 6, 12, and 24 months s/p completion of chemotherapy

  • Neck irradiation performed during treatment: Obtain TSH level at 1, 2 and 5 years

Notes

• B cell lymphoma

• Immunosuppressed patients are 10 times greater risk for developing condition

• Subtypes include

  • Nodular sclerosis: Approximately 70% of cases and more common in adolescents

  • Mixed cellularity: 20-25% of cases and more common in younger children and older adults

• ABVD: Commonly used chemotherapy regimen consisting of doxorubicin, bleomycin, vinblastine, and dacarbazine 

Chronic Lymphocytic Leukemia

65 y/o white male with h/o previous radiation treatment presents with new onset fatigue. Reports recent low grade fevers, night sweats, and easy bruising/bleeding. Weight loss, lymphadenopathy, and hepatosplenomegaly on exam.

• Labs

  • CBC and immunophenotyping shows anemia, thrombocytopenia, and leukocytosis with > 20,000 WBCs, > 5,000 B lymphocytes, and > 500 neutrophils/mL

  • Obtain CMP, PT, PTT, INR, peripheral blood smear

  • If patient develops fever: Obtain urinalysis, urine culture, blood culture, and CXR

• Administer yearly influenza vaccine and pneumococcal vaccine every 5 years, avoid live vaccines

• Refer to hematology/oncology for bone marrow biopsy and further evaluation

• Counseling

  • Treatment may include a combination of chemotherapy, radiation, monoclonal antibodies, and/or stem cell transplant

  • Survival rate is > 80% at 5 years

Notes

• Epidemiology and diagnosis

  • 85% of cases occur in patients age 65 or older

  • Only 15% of patients present with constitutional symptoms

  • Splenomegaly is the most common presentation (75% of patients)

  • Half of all diagnoses are made incidentally based on bloodwork

• Treatment

  • Asymptomatic patients with no anemia and fewer than 3 involved lymph nodes may be monitored without treatment

  • Patients with fever and <500 neutrophils per microliter should be started on antibiotics and admitted for further evaluation

Sickle Cell Crisis

Pt > 6 months old with h/o sickle cell anemia presents with severe acute-onset pain. Reports recent cold exposure, dehydration, alcohol consumption, and current menses. ROS positive for headache, chest pain, dyspnea, abdominal pain, flank pain, dysuria, change in urine color/appearance, hip pain, hand/foot pain. Tachycardia, tachypnea, SPO2 < 92%, jaundice, abdominal pain, hepatomegaly, costovertebral angle tenderness, facial droop, slurring of speech, unilateral weakness on exam.

• Initial Labs

  • CBC, reticulocyte count, type/cross, CMP, U/A, EKG

  • Reproductive age female not currently menstruating: Urine beta-hCG

• Start pain control within 30 minutes of initial evaluation and titrate until pain is controlled or patient displays somnolence

  • Starting dose for opioid tolerant adult: Oxycodone 4 mg q4 hours PRN

  • Home dose > starting dose (above): Start dose that appropriately controlled patient’s pain during most recent crisis

• Potential Complications

  • Chest pain and/or dyspnea

    • DDX: Pulmonary embolism vs. acute coronary syndrome vs. acute chest syndrome (see below)

    • Overall increased index of suspicion if tachycardia, tachypnea, decreased SPO2, thrombocytopenia

    • Obtain troponin, EKG, CXR +/- DVT U/S, CT angiogram

  • Renal involvement

    • CVA tenderness → concern for pyelonephritis → renal ultrasound

    • U/A with leukocyte esterase +/- nitrites → concern for UTI

    • U/A with hematuria → concern for renal infarction

  • Jaundice

    • DDX: Hemolytic transfusion reaction vs. hepatobiliary disease (e.g. biliary complications including surgical abdomen)

    • Obtain PT/INR, LDH, RUQ U/S

  • Extremity pain

    • Fingers/toe pain: Dactylitis vs. gout → uric acid level, x-ray of affected extremity

    • Calf pain → concern for DVT → DVT U/S of affected extremity

    • Hip pain → concern for avascular necrosis → hip x-ray +/- MRI

  • Focal neurologic deficit: R/o stroke

• Treatment

  • Oxygen by nasal cannula to maintain SPO2 > 92%

  • Adult patient: Heparin 5,000 units SQ q12 hours for VTE prophylaxis

  • Acute chest

    • Incentive spirometry at bedside

    • Administer D5 1/2 NS at 1.5 x maintenance for 24 to 48 hours

    • Start cefotaxime 1g IV q8h + azithromycin 500 mg PO qd x 7 days

    • Heparin for VTE prophylaxis regardless of age (reference dosing)

    • Initiate transfusion therapy per hematology/oncology

• Consults

  • Notify hematology/oncology

    • Discuss potential need for exchange transfusion

    • Discuss starting hydroxyurea 15 mg/kg/day at discharge

  • Cholecystitis: Consult general surgery

  • Renal infarction: Consult nephrology

Notes

• A sickle cell crisis is PAINFUL - adjust acute pain medication based on patient’s reported pain

• Risk factors for sickle cell crisis include cold exposure, dehydration, alcohol consumption, and current menses

• Increased suspicion for

  • Acute chest in patient with leukopenia or leukocytosis

  • PE in patients with h/o obesity, decreased mobility, splenectomy

Angioedema

Bradykinin-Mediated

Pt with h/o HTN, HFpEF presents with acute onset angioedema. Reports recent increase in ACE inhibitor dose, abdominal pain. Family history of angioedema. Hypotension, rigid abdomen, edematous swelling involving face/tongue/hands/buttocks/genitals on exam. No urticaria noted.

• Obtain CBC, CMP, U/A, ESR, C4 protein level

• Treatment

  • Stop ACE inhibitor

  • Administer 1L NS bolus and re-evaluate BP

  • Administer one of the following and repeat q3 hours PRN

    • 0.5 mL racemic epinephrine 2.25% solution

    • 0.3 mg epinephrine IM

  • Administer 1u fresh-frozen plasma

  • Consider methylprednisolone (Solu Medrol) 40 mg IV q6 hours, diphenhydramine (Benadryl) 25 mg IV q6 hours

  • Concern for hereditary angioedema: C1-inhibitor concentrate if available

• Patient advised to follow-up with allergy specialist

Notes

• ACE inhibitors produce bradykinin-mediated angioedema

• No mast cell degranulation/histamine release = no urticaria

• GI tract swelling may mimic a surgical abdomen on exam

• If concerned about an allergic component, Solumedrol and Benadryl can be started

Histamine-Mediated Angioedema

Pt with h/o multiple allergies presents with acute onset swelling and hives. Pt consumed peanut/lobster/tomato omlet and self-administered PCN 1 hour prior to symptom onset. Stung by wasp en route to hospital. Reports previous episodes of similar symptoms and recent increase in nocturnal pruritus. Medications include codeine, muscle relaxants, vancomycin, aspirin, NSAIDs. Swelling of face/tongue/hands/buttocks/genitals, multiple round and irregularly shaped pruritic wheals (urticaria) on exam.

• Obtain CBC, CMP, U/A, ESR

• Discontinue medications that may be contributing to condition

• Concern for airway compromise/distributive shock

  • Administer IM epinephrine

  • Consult ENT

  • Prepare for intubation

• Chronic urticaria

  • Start loratadine (Claritin) 10mg daily

  • Diphenhydramine (Benadryl) 25 mg at bedtime for nocturnal pruritus

  • Add ranitidine (Zyrtec) 150 mg daily for additional symptom control

  • Prednisone 40 mg daily x5 days for acute, severe symptoms

  • Epinephrine auto injector (EpiPen) 0.3mg for emergencies

  • Refer to allergy-immunology specialist

  • Pt counseled about sedating effects of first generation H1 blockers (diphenhydramine)

  • Pt instructed in use of EpiPen

Notes

• Urticaria = histamine release = treatment with antihistamine agents

• Common causes of histamine release include drugs (PCN, cephalosporin), hymenoptera insect (wasp, ant) venom, foods, latex, environmental allergies

• Histamine-mediated urticaria is treated with H1 blockers (loratadine, diphenhydramine) and H2 blockers (ranitidine)