american college of physicians kansas chapter conference october 3, 2013 ky stoltzfus, md
DESCRIPTION
American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD University 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 - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/1.jpg)
American College of Physicians Kansas Chapter Conference
October 3, 2013
Ky Stoltzfus, MDUniversity of Kansas Medical
Center
![Page 2: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/2.jpg)
Have I got a case for you...
Or should it be:
Have I got a case for you?
![Page 3: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/3.jpg)
62 year old man with acute promyelocytic leukemia
presents with shortness of breath and chest pain.
![Page 4: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/4.jpg)
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.
![Page 5: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/5.jpg)
Recent diagnosis of APL Bone marrow hypercellular 95%
with 80% blast or promyelocytes Started All-Trans Retinoic Acid
(ATRA) therapy the day of admission
![Page 6: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/6.jpg)
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
![Page 7: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/7.jpg)
ROS
Positive for the following, otherwise negative: Gen: fatigue, malaise, anorexia CV: chest pain Pulm: SOB, cough, sputum production Neuro: dizziness
![Page 8: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/8.jpg)
PMH HTN CAD Type II DM Atrial fibrillation
PSH None
![Page 9: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/9.jpg)
Meds tretinoin
• flecainide
• simvastatin
• zolpidem
• fish oil /omega-3 fatty acids
• atenolol
• polyethylene glycol (MIRALAX)
• pantoprazole
![Page 10: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/10.jpg)
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
![Page 11: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/11.jpg)
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
![Page 12: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/12.jpg)
EKG: atrial fibrillation, rate 99, LVH, no ST or T wave changes, no Q waves
![Page 13: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/13.jpg)
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
![Page 14: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/14.jpg)
![Page 15: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/15.jpg)
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
![Page 16: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/16.jpg)
What would you do next?
Diurese patient Possible emperic antibiotics Consider CT chest or VQ scan Contact your blood bank
![Page 17: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/17.jpg)
![Page 18: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/18.jpg)
TRALI
American Society of Hematology Education Program
http://asheducationbook.hematologylibrary.org/content/2006/1/497.full
![Page 19: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/19.jpg)
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
![Page 20: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/20.jpg)
TRALI attributed to donor leukocyte antibodies.
Alternate mechanism: “two hit” or “neutrophil priming” hypothesis.
![Page 21: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/21.jpg)
Incidence
1:432 whole blood platelets
1:557,000 red cells
Plasma transmission variable (depends on region of the country)
![Page 22: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/22.jpg)
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.
![Page 23: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/23.jpg)
Follow up
Extremely important to notify your blood bank if TRALI is suspected.
Donors can tracked.
FDA is notified.
![Page 24: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/24.jpg)
Case continued
Patient had worsened respiratory failure and subsequent multi-organ failure. He died in ICU on maximal life support.
![Page 25: American College of Physicians Kansas Chapter Conference October 3, 2013 Ky Stoltzfus, MD](https://reader036.vdocuments.net/reader036/viewer/2022062500/56815a94550346895dc80d84/html5/thumbnails/25.jpg)
Summary
Suspect TRALI if respiratory symptoms follow transfusion.
Keep your differential diagnosis broad.
Report suspected cases of TRALI to blood bank immediately.