American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD
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Transcript of American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD
American College of Physicians Kansas Chapter Conference
October 3, 2013
Ky Stoltzfus, MDUniversity of Kansas Medical
Center
Have I got a case for you...
Or should it be:
Have I got a case for you?
62 year old man with acute promyelocytic leukemia
presents with shortness of breath and chest pain.
HPI: Chest pain over left sternum, dull,
7/10 severity, constant, began 4-5 hours prior, not relieved or worsened by any factors.
Associated SOB, started at same time, some cough and white sputum. Can't lay flat easily, gets “winded” with walking.
Recent diagnosis of APL Bone marrow hypercellular 95%
with 80% blast or promyelocytes Started All-Trans Retinoic Acid
(ATRA) therapy the day of admission
During visit he was noted to have WBC 0.7 K/uL Hgb 7.5 g/dL Platelets 13 K/uL
Transfused 1 unit platelets
ROS
Positive for the following, otherwise negative: Gen: fatigue, malaise, anorexia CV: chest pain Pulm: SOB, cough, sputum production Neuro: dizziness
PMH HTN CAD Type II DM Atrial fibrillation
PSH None
Meds tretinoin
• flecainide
• simvastatin
• zolpidem
• fish oil /omega-3 fatty acids
• atenolol
• polyethylene glycol (MIRALAX)
• pantoprazole
Soc Hx Married Nonsmoker, no EtOH, no illicit drugs
Fam Hx Father – prostate CA, died 82yo Mother – CAD, HTN, living 84yo Siblings – healthy No other cancer history
Physical Exam
38.1C P99 R21 BP110/78 O2 87%RA
Gen: Sitting, in moderate respiratory distress, alert, oriented x 3
Neck: No carotid bruits, no JVD
CV: Irregular, no S3 or S4, no murmur
Pulm: Crackles in bilateral bases and mid-lung fields
Abd: Soft, nontender, nondistended
Extrem: no cyanosis or edema
Pulses: 1+ bilateral radial, dorsalis pedal, posterior tibialis
EKG: atrial fibrillation, rate 99, LVH, no ST or T wave changes, no Q waves
Labs:
Hgb 7.5, WBC 0.8, Plat 27
32%N, 3%Band, 30L, 4M, 31% blasts
Na 131, Cl 101, bicarb 22, lactate 2.1, Cr 1.4, Tbili 1.5, LDH 299
Trop 0.01, BNP 185
What's in your differential diagnosis?
Here's mine: CHF exacerbation Transfusion Associated Cardiac Overload
(TACO) PNA, atypical TRALI (Transfusion Associated Acute Lung
Injury) PE
What would you do next?
Diurese patient Possible emperic antibiotics Consider CT chest or VQ scan Contact your blood bank
TRALI
American Society of Hematology Education Program
http://asheducationbook.hematologylibrary.org/content/2006/1/497.full
TRALI
TRALI is characterized by acute non-cardiogenic pulmonary edema and respiratory compromise in the setting of transfusion
Normal CVP and wedge pressure
Mimics ARDS
TRALI attributed to donor leukocyte antibodies.
Alternate mechanism: “two hit” or “neutrophil priming” hypothesis.
Incidence
1:432 whole blood platelets
1:557,000 red cells
Plasma transmission variable (depends on region of the country)
Testing
HLA class I or class II, or neutrophil-specific antibodies in donor plasma and the presence of the cognate (corresponding) antigen on recipient neutrophils.
Takes weeks to obtain this.
TRALI is still a clinical diagnosis.
Follow up
Extremely important to notify your blood bank if TRALI is suspected.
Donors can tracked.
FDA is notified.
Case continued
Patient had worsened respiratory failure and subsequent multi-organ failure. He died in ICU on maximal life support.
Summary
Suspect TRALI if respiratory symptoms follow transfusion.
Keep your differential diagnosis broad.
Report suspected cases of TRALI to blood bank immediately.