Morning Report 08/23/2021

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


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






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.


The big idea, and a few finer points.

![TLS]( =500x500 β€˜JAMA Oncology 2018, TLS Review’)

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 β€œ25% 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 β€œThings 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

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