How can somthing so little cause something so big????

Above is a picture of leishmaniasis - visceral leishmaniasis is one of the causes of massive splenomegaly which can be distinguished from the listed causes of splenomegaly below by the fact that they are highlighted RED

Hematologic
Lymphoma, usually indolent variants
Acute and chronic leukemias (CML)
Polycythemia vera

Myelofibrosis
Multiple myeloma
Essential thrombocythemia
Acute and chronic hemolytic anemias (thalassemia)
Sickle cell diseas

Malignancy
Hematologic (see above)
Primary splenic tumors
Metastatic solid tumors

Infection
Viral - hepatitis, infectious mononucleosis, cytomegalovirus
Bacterial - salmonella, brucella, tuberculosis (MAC )
Parasitic - malaria, schistosomiasis,toxoplasmosis, leishmaniasis (Kala-azar)
Infective endocarditis
Fungal

Collagen Vascular Disease
Sarcoid
Systemic lupus erythematosus
Rheumatoid arthritis (Felty syndrome)


Infiltrative
Malignancy (infiltrative, primary tumor, metastatic tumor)
Gaucher's disease
Niemann-Pick disease
Amyloid
Glycogen storage disease
Langerhans cell histiocytosis
Hemophagocytic lymphohistiocytosis


Congestive
Cirrhosis
Heart failure

Thrombosis of portal, hepatic, or splenic veins

The internist's tumor.....

Renal cell carcinoma is often dubbed the 'internist's tumor' likely because of the many paraneoplaastic syndromes that have been associated with this cancer. The classic triad of "hematuria, flank pain and abdominal mass" as a presentation occurs generally in <10%>

Clinical syndromes....

1. anemia: can have the picture of anemia of chronic disease and precede the diagnosis of RCC.

2. hepatic dysfunction / STAUFFER's Syndrome: may be the result of liver mets but in the case of Stauffers syndrome occurs without any clear evidence of metastases and may be reversed by nephrectomy.

3. Fever: in up to 1/5 of people with additional constitutional symptoms

4. hypercalcemia: from bony mets, increased prostaglandins or PtHRP

5. erythrocytosis

6. thrombocytosis

7. AA amyloidosis

8. other hormonal overproduction....gonadotropins, human chorionic somatomammotropin, an ACTH-like substance, renin, insulin, glucagon

Do you see what I see......

The art of fundoscopy remains an important skill. When talking about hypertension some potentail changes include:

Mild Retinopathy : Retinal arteriolar narrowing, arteriolar wall thickening or opacification (copper wiring), and arteriovenous nicking (see above picture)

Moderate Retinopathy: Hemorrhages, either flame or dot-shaped, cotton-wool spots, hard exudates, and microaneurysms (see above)

Severe Retinopathy: Some or all of the above, plus optic disc edema (papilledema- see below)

All 'myx'ed up....

When discussing a case of hypothyroidism it important to consider the differential of hypothyroidism.....

Causes of Hypothyroidism:
Primary:

• Hashimotos
• RAI
• Surgery
• Subacute Thyroiditis
• Excess Iodine Intake
• Meds: lithium, amiodarone
• Iodine deficiency

Secondary Hypothyroidism (pituitary)
Tertiary Hypothyroidism (hypothalamus)
Peripheral Resistance to thyroid hormone

Investigations:

• TSH, FT3, FT4
• Anti-thyroid antibodies (anti-thyroglobulin, anti-TPO)
• Complications: CBC (normocytic anemia), lytes (hypoNa), fasting lipids, CK

Treatment:
L-thyroxine replacement (start at 25 - 50 mcg daily & increase slowly)
25 mcg daily for those with CAD, 50 mcg daily for elderly (age > 50)
full dose (usually 1-2mcg/kg daily) for young pt’s with no CAD
Titrate q 4wks based on TSH, FT4


Consider severity of hypothyroidism…..? myxedema coma:

Clinical Features:

-hypothermia
-hypotension / bradycardia
-hypercarbia
-hypoNa
-hypoGlu
-elevated CK

Management of this emergency……30-40%mortality!

• Admit to monitored setting
• Supportive
• Support ventilation as needed
• Monitor ABG’s
• Support BP with fluids / pressors
• Passive warming
• iv glucose for hypoglycemia – ± stress steroids, test for concomitant adrenal insufficiency
• Watch Na- likely SIADH

Specific:

• L-thyroxine iv bolus, followed by daily dosing (iv/PO)
• Adrenal insufficiency may be precipitated so hydrocortisone until plasma cortisol is known
  can have associated primary adrenal or secondary adrenal insufficiency
• Treat underlying cause (consider broad-spectrum Abx until cultures back)
• Refer to Endocrine