Internal Medicine Cases

Consistent with physical examination and clinical suspect, cxr was compatible with right sided pleural effusion.
Any pleural effusion should be undergone fluid analysis except the one suggestive of heart failure etiology (bilateral pleural effusion with right side dominance without signs of infection, fever, consolidation, and without significant difference in the fluid levels)

So the patient underwent pleural fluid aspiration under the sonography guide and here is his pleural fluid appearance!

Case number 28

A 45-year-old man with no past medical history came to the emergency ward with the chief complaint of progressive at rest dyspnea and right hemithorax pleuretic chest pain. He was a smoker (20 pack year) and also an opium addict.
His vital signs:
BP 140/80
PR 100
RR 28
SPO2 92% room air

On the physical exam, there were absent respiratory sounds in the right hemithorax with reduced tactile and vocal fermitus, and dullness in percussion.


His chest x-ray is obvious in the picture.

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)

Time-specific algorithm for neutropenic fever (Up-to-date)

Up-to-date algorithm for neutropenic fever

Inspite of 3 liters isotonic administration, the patient remained anuric and only 20 cc urine was present in the urine bag

The patient was not edematous and heart and lung sounds in auscultation remained clear with no obvious pathology.

Follow up Lab tests

K 3.6
P 7.1
Mg 1.5
Ca 7.1
Alb 3.1
Uric acid 10.6

Random urine sample
Cr 50 mg/dl
Uric acid 60 mg/dl

In sonography, kidneys were normal sized with increased corticomedullary differentiation and increased paranchymal echo with no signs of hydronephrosis.

Case follow up

After initial history taking, 1 lit isotonic saline was infused for the patient.
Foley catheter was fixed but there were no signs of urine in the urine bag.

Brain CT scan showed no specific pathology.

Blood cultures were obtained immediately and empiric antibiotic therapy was started as soon as possible.