Paraneoplastic phenomena - divineinterventionpodcasts



119Hypotensive, temp103, crackles at LLB, productive cough for 2-3 days: pneumonia sepsisTx: cover MRSA, pseudomonasMRSA: vancomycin (--| D-ALA), linezolid (--| 50S), daptomycin (--| gram+ by poking holes in cell membrane), ceftaroline (5th gen ceph), TMP-SMX, clindamycin (--| 50S), doxycycline Pseudomonas: ceftazidime (3rd gen ceph), cefepime (4th gen ceph), aztrenonam (monobactam), fluoroquinolones, aminoglycosides (--| bactericidal 50S, *do not cover anaerobes), pip-tazo, carbapenems2mos fatigue, hyponatremic, hyperkalemic, elevated eosinophils, 80/50: Addison's diseaseRF: other autoimmune diseasePath: autoimmune destruction of adrenal cortexZona glomerulosa: mineralocorticoids i.e. aldosterone Not affected by secondary adrenal insufficiency (failure of hypothalamus)Aldosterone is controlled by RAAS Zona fasciculata: cortisol--| eosinophils DDx of eosinophilia Zona reticularis: sex steroidsAlpha intercalated cell pumps out protons into urine; aldosterone helps make this happen through excretion of K+. If no aldosterone --> non-anion gap metabolic acidosis (Type IV RTA) Dx: ACTH/cosyntropin --> cortisol levels will not riseTx: fludrocortisone Dialysis a month ago, chest pain, difficulty breathing, bilateral/extremity edema, crackles: high-output heart failure DDx: AV fistula (arteries-veins w/o capillary resistance), Paget's disease (bone marrow becomes hypervascular), AV malformation, severe anemia (CO increases to increase O2 delivery)Blood glucose 900, HCO3 15, Na 125: DKAVs. HHNS (not acidotic)Pathophys: insulin prevents release of glucagon --> decreased lipolysis, production of ketone bodies Skin hyperpigmentation, Hgb 15, blood glucose 300: hereditary hemochromatosisPathophys: C282Y mutation --> increased reabsorption of iron from gut"bronze diabetes" d/t iron-Fenten (free radical) reaction that leads to fibrosis of pancreasSkin: @skin, gonads, heart (1. restrictive 2. dilated cardiomyopathy), calcium-pyrophosphate-deposition disease/CPPD/pseudogoutCPPD ddx: hereditary hemochromatosis, Gitelman's syndrome (loss of ions @ tubules)Positive birefringence, rhomboid crystals, chrondocalcinosis on imagingDx: ferritin Tx: phlebotomy "menstrual cycles are monthly phlebotomy" --> delayed onset in women Pneumococcal pneumonia, 118 Na: SIADHPathophys: any lung or brain pathology!DDx: small-cell lung cancer (ACTH, SIADH, Lambert-Eaton)Sx: euvolemic hyponatremiaUrine is hyperosmolar Tx: fluid restriction Vs. diabetes insipidus: not observing effects of ADH in body --> not reabsorbing water --> hyperosmolarity, hypernatremia, low urine osmolarity Dx: water deprivation, ADH analog (desmopressin) urine osmolarity shoots up: ADH deficiency @ supraoptic nucleus of hypothalamus = central DIUrine osmolarity does not change: nephrogenic DIRF: lithium (also suicide preventative), demeclocyclineVs. Psychogenic polydipsia: serum osmolarity goes down, urine osmolarity goes down (everything working fine) ?Paraneoplastic phenomenaEtiologyPathophysHigh hematocritpolycythemia vera, hepatocellular carcinoma, renal cell carcinoma?Moon facies, hypercortisolismsmall cell lung cancerEctopic production that does not suppress with high dose dexamethasoneSmoker, pain in bones, finger clubbinglung cancerhypertrophic pulmonary osteoarthropathy Dermatomyositis, polymyositislung cancer?Sudden-onset acanthosis nigricans/Leser Trelat signGI cancer?High Ca (tx fluids, biphosphonates i.e zoledronic acid)multiple myeloma, squamous-cell lung cancer, mets, sarcoidosis multiple myeloma (IL-1 = osteoclast-activating factor), squamous-cell lung cancer (PTHrP), lytic mets (i.e. from thyroid/renal cancer), blastic mets (i.e. from prostate/breast cancer), sarcoidosis (non-caseating granulomas produce 1alpha-hydroxylase calcidiol --> calcitriol --> reabsorption of Ca/P in gut) ................
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