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The Yellow Man

The Yellow Man. Betsy Trowbridge Case Presentation April 12, 2006. History. A 90 yo male walked into clinic after his pharmacist told him to go see his doctor because he was yellow and it might be from his cholesterol medicine. His sister noticed he was yellow the day before.

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The Yellow Man

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  1. The Yellow Man Betsy Trowbridge Case Presentation April 12, 2006

  2. History • A 90 yo male walked into clinic after his pharmacist told him to go see his doctor because he was yellow and it might be from his cholesterol medicine. His sister noticed he was yellow the day before. • He reports feeling fatigued for a few months, worse in the last two weeks. • ROS positive for dark urine, otherwise neg

  3. PMH • COPD • HTN • ASHD with drug eluding stent placed 2 months earlier. • Bronchioalveolar lung Ca with RUL resection in 1993 • TURP, cholecystectomy, R knee replacement, L hemicholectomy • Increased cholesterol

  4. History • Allergies: NKDA • Meds: ASA 81 mg po daily Verapamil 180 mg po daily NTG patch .2 mg on AM off PM Plavix 75 mg po daily Simvastatin 10 mg po daily

  5. Physical Exam • General: jaundiced over whole body with icteric sclerae • No adenopathy • Heart: II/VI SEM • Abd: no hepatosplenomegaly • Ext: +2 edema • Skin: 1 cm sub Q nodule L posterior shoulder

  6. Diagnosis • Painless Jaundice

  7. Painless JaundiceDifferential • Cancer: pancreatic, cholangiocarcinoma • Viral Hepatitis • Drugs • Primary Biliary Cirrhosis • Hemolytic Anemia • Gilbert’s syndrome • CHF • End-stage Liver disease • Primary Sclerosing Cholangitis

  8. Next Best Test • Bilirubin total • Bilirubin, direct and indirect • LFT’s • CBC • Lipase • CT abd/pelvis • Abd ultrasound

  9. Bilirubin Results • Total Bilirubin 7.6 (increased) • Unconjugated Bilirubin 6.7 (increased) • Conjugated Bilirubin .9 (mildly increased) • Bilirubin is a blood breakdown product that is removed from the blood by the liver. When is is still in the blood it is unconjugated. When it enters the liver cells the bilirubin is conjugated and secreted into bile which is eliminated in the feces.

  10. Unconjugated Hyperbilirubinemia(In blood) • Increased Bilirubin production • Hemolytic Anemia • Impaired bilirubin uptake • CHF • Drugs • Impaired bilirubin conjugation • Gilbert’s syndrome

  11. Cojugated Hyperbilirubinemia (In liver cells) • Biliary Obstruction • Gall stones • Cancer: pancreatic, cholangiocarcinoma • Primary sclerosing cholangitis • Intrahepatic cholestasis • Viral hepatitis • Drugs • Primary Biliary Cirrhosis • End-stage liver disease

  12. Further Tests • Hct 21.5 Hgb 7.1, Plts 182, MCV 110.5 • Diff. 39% neut, 35% lymphs, 18% monos, 4% basos, 10% nuc. RBCs, 3% bands, 1% meta’s. • LFT’s nl except ALT 22, AST 62 • LDH 1236

  13. Diagnosis • Hemolytic anemia • Shortened survival of RBCs. Usual survival 120 days. • Divided into intracorpuscular (intrinsic) and extracorpuscular (extrinsic) to the RBC. Intrinsic are hereditary like PNH. Extrinsic are acquired conditions that lead to RBC destruction.

  14. Case • Patient called at home and admitted to the hospital. • Ferritin 542, serum iron 123, folate 8.6 • Retic count 12.4 with absolute count 238. • Urine hemosiderin positive • Positive direct Coombs test • Peripheral smear is negative • Haptoglobin very low

  15. Extracorpuscular Causes • Antibodies against the RBC membrane, AIHA • Hypersplenism • Trauma: DIC, TTP • Destruction of RBCs by pathogen: Malaria

  16. Diagnosis Warm Auto Immune Hemolytic Anemia IgG and C3 positive

  17. Etiology • Lymphoma • CLL • SLE • Drugs: PCN • Idiopathic: Greater than 50%

  18. Case • CT scan of neck, lungs, abd, and pelvic revealed a 4 cm apical mass suspicious for recurrent bronchioalveolar carcinoma.

  19. Treatment • High dose steroids early, 1mg/kg to induce remission of antibody titers • Blood transfusions if symptomatic Dangerous with high risk of incompatibility. Must premedicate patient. • Splenectomy • Other immunosuppressive drugs • Follow daily hgb, retic count and indirect bilirubin for response to treatment • Treat underlying cause

  20. Case • Likely idiopathic or secondary to presumed recurrent lung cancer. • Pt did receive two units of blood without complications only after OK from Hematology. • Dilemma about lung lesion. Could not stop Plavix because of drug eluding stent and DVI would not biopsy.

  21. Case • Pt responded to treatment • Pt followed weekly in Hem Clinic with prednisone tapered to 20 mg po BID with stable count at 8 weeks.

  22. Summary • Painless Jaundice: Get bilirubin total, direct and indirect to guide next steps in diagnosis. • Hemolytic anemia: YES if increased LDH and decreased haptoglobin. If direct coombs postive start with aggressive steroid treatment early. Use blood transfusions carefully.

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