beau hilton

Morning Report 08/23/2021

Details modified, generalized, and otherwise fudged to be HIPAA-compliant.

HPI

72F with chest pain, abdominal pain, and constipation.

2-3mo weight loss, night sweats.

2-3wk +perineal ?cyst, initially ttp and hurt to walk, but now nontender.

~1wk constipation, BRB on TP.

+crampy LLQ pain 8/10, x3-4 days, improves with positioning (supine with head raised somewhat, 3-4 pillows).

+LUQ and left-sided chest pain x1-2 days, radiates to L arm, not related to exertion, lasts a few minutes.

OP Meds

PMSHx

SHx

FHx

PE

Labs

Other studies

Further notes on hospital course

And then…

Diagnosis is… MDS/MPN/MF NOS.

I.e., who knows.

Started on hydroxyurea and decitabine, c/b recurrent bacteremia, so currently tx on hold.


TLS

The big idea, and a few finer points.

TLS

Cairo-Bishop classification system

(Most of the following derived from Chapter 4 of the American Society of Nephrology online Onco-Nephrology curriculum, which is good and great.)

Laboratory TLS

Definition: Chemotherapy plus the two or more of the following within 3d before or 7d after initiation (so doesn't account for the spontaneous TLS seen in our patient).

Metabolite/Electrolyte Criterion
Uric Acid >=8 mg/dL or 25% increase from baseline
Potassium >=6mEq/L or 25% increase from baseline
Phosphorus >=4.5mg/dL or 25% increase from baseline
Calcium 25% decrease from baseline

The “25% increase/decrease” part is contested, as it may not be clinically meaningful if the value stays within the normal range.

Clinical TLS

Laboratory TLS and one or more of
creatinine >= 1.5 ULN (Note: just use AKI criteria)
cardiac arrhythmia or sudden death
seizure

Treating TLS

IVF, electrolytes, rasburicase.

Rasburicase is the subject of a recent “Things We Do for No Reason.“

Pay-walled article, PDF made available by the authors

TL;DR: the evidence is thin, but could be reasonable to - ppx w IVF and allopurinol for low-med risk, - use single 3mg dose rasburicase as ppx in high-risk disease (don't use weight-based dosing), - tx active TLS (laboratory or clinical) with aggressive fluid resuscitation and electrolyte mgmt, possibly single 3mg dose.

Hard outcomes in support of rasburicase are generally lacking, e.g. consistently reducing renal injury, renal failure, length of stay.

It also seems like the classification criteria need revamping, with a larger N. It's been a while. However, like redefining fever, it's difficult to get a clean slate, because we act on the established criteria so aggressively.


MDS/MPN overlap syndromes

Not much to say here, except that the dx is not always clear-cut, even with BMBx and NGS data, so the clinical picture matters, and sometimes we have to shoot in the dark.


Last updated: 2021-08-22




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