A 26-year-old man complains of heaviness in the left testicle. There has been no recent trauma. Physical examination reveals a 3-cm painless firm mass that clearly arises from the testicle. The physical examination is otherwise unremarkable. Abdominal CT scan shows matted periaortic lymphadenopathy, with the largest node approximately 3.5 cm in size. CT of the chest shows no abnormalities.
In addition to urological referral, what should be the next diagnostic study?
This patient has testicular carcinoma. A solid mass arising from the testis (ie, not an extratesticular scrotal mass) is almost always malignant. Bulky retroperitoneal lymphadenopathy is characteristic of the metastatic pattern of testicular cancer. The evaluation first involves staging the tumor with CT rather than PET scanning. Stage I is confined to the testicle, stage II involves retroperitoneal or periaortic lymphadenopathy, and stage III implies distant spread to mediastinal or supraclavicular nodes, lung, or brain. The intensity of treatment is decided by placing the patient into good, intermediate, or poor prognostic groups. This is based on histological type (determined from the radical inguinal orchiectomy), stage, and tumor markers (AFP, β-hCG, and LDH). Diagnosis is often confirmed by orchiectomy as needle biopsy or aspiration is usually not diagnostic. In general, favorable prognostic features include semi-nomatous histology, absent or (in the case of nonseminomatous tumors) low levels of serum tumor markers, absence of metastases beyond the retroperitoneal nodes, and testicular site of origin (extragonadal tumors carry a less favorable outlook). Favorable prognosis seminomas are often cured with orchiectomy and retroperitoneal radiation therapy. Chemotherapy is usually necessary to cure nonseminomatous tumors, but even intermediate prognosis nonseminomatous tumors can be cured 80% of the time. Other cancers may also be associated with tumor markers (CEA in colon cancer and α-fetoprotein in hepatocellular carcinoma).
A 50-year-old man presents with 3 days of fever, diffuse bone pain, and extreme weakness. He denies any sick contacts. On examination, there is conjunctival pallor, dried blood on the nasal mucosa, and ecchymoses on both lower extremities. There is no lymphadenopathy or hepatosplenomegaly. Urinalysis and chest x-ray are normal. The peripheral blood smear is shown.
What is the most likely diagnosis?
Patients with acute myeloid leukemia (AML) usually present with nonspecific symptoms like fever, bone pain, headache, night sweats, and fatigue. Bone pain is attributed to the expansion of the marrow by leukemic cells. Laboratory abnormalities include anemia and thrombocytopenia. Patients with French American British (FAB) classification M3 variety (acute promyelocytic leukemia) of AML can also present with symptoms of disseminated intravascular coagulation (DIC) or can develop it during treatment. The blood smear in this patient shows a leukemic myeloblast containing an Auer rod. Auer rods are formed by fusion of lysosomal granules and appear as clumps of azurophilic, granular, needle-shaped material found in the cytoplasm of blast cells. Myelofibrosis would have a more insidious course and is usually associated with splenomegaly. Multiple myeloma can present with bone pain, but patients usually have chronic pain that is localized to the back or ribs. Acute lymphocytic leukemia (ALL) is less common in adults, and patients usually have generalized lymphadenopathy. Auer rods are found in myeloblasts but not in lymphoblasts of ALL. In ALL bone marrow biopsy would show a predominant lymphocytic pattern rather than myeloid predominance.
A 70-year-old intensive care unit patient complains of fever and shaking chills. The patient develops hypotension, and blood cultures are positive for gram-negative bacilli. The patient begins bleeding from venipuncture sites and around his Foley catheter. Laboratory studies are as follows:
Which of the following is the best course of therapy in this patient?
This patient with gram-negative bacteremia has developed disseminated intravascular coagulation (DIC), as evidenced by multiple-site bleeding, thrombocytopenia, fragmented red blood cells on peripheral smear, prolonged PT and PTT, and reduced fibrinogen levels from depletion of coagulation proteins. Initial treatment is directed at correcting the underlying disorder—in this case, infection. Although heparin was formerly recommended for the treatment of DIC, it is now used rarely and only in unusual circumstances (such as acute promyelocytic leukemia). For the patient who continues to bleed, supplementation of platelets and clotting factors (with fresh frozen plasma or cryoprecipitate) may help control life-threatening bleeding. Red cell fragmentation and low platelet count can be seen in microangiopathic disorders such as thrombotic thrombocytopenic purpura (TTP), but in these disorders the coagulation pathway is not activated. Therefore, in TTP the prothrombin time, partial thromboplastin time, and plasma fibrinogen levels will be normal. Plasmapheresis, vitamin K therapy, and RBC transfusion will not correct the underlying cause.
A 30-year-old woman with Graves disease has been started on pro-pylthiouracil. She complains of low-grade fever, chills, and sore throat.
Which of the following is the most important initial step in evaluating this patient’s fever?
Propylthiouracil often causes a mild leukopenia that does not require discontinuation of the drug. Drug-induced agranulocytosis,however, is a life-threatening complication occurring in 0.1% to 0.2% of patients on antithyroid medications and requires immediate discontinuation of the drug. Agranulocytosis is an immune-mediated disorder; the absolute neutrophil count is often extremely depressed (usually < 100). Generally the neutrophil count will recover 5 to 7 days after the offending drug has been discontinued. During this time the patient is at grave risk of septicemia. Although blood cultures and CXR may be indicated in this patient prior to the administration of antibiotics, the most important initial step is evaluating the white blood cell count. Evaluation of thyroid function (with TSH or T3) will not diagnose the agranulocytosis.
A 62-year-old woman has noted fever to 38.3°C (101°F) every evening for the past 3 weeks, associated with night sweats and a 15-lb weight loss. Physical examination reveals matted supraclavicular lymph nodes on the right; the largest node is 3.5 cm in diameter. She also has firm rubbery right axillary and bilateral inguinal nodes. Excisional biopsy of one of the nodes shows diffuse replacement of the nodal architecture with large neo-plastic cells which stain positively for B-cell markers. No Reed-Sternberg cells are seen.
Which statement most accurately reflects her prognosis?
This is a classic presentation of diffuse large cell lymphoma. These neoplasms usually present with a rapidly enlarging nodes and B symptoms (fever, night sweats, > 10% weight loss). Extranodal disease (eg, gastric involvement) is occasionally seen, whereas extralymphatic disease is unusual in the more indolent small cell lymphomas. Although Hodgkin disease can also present in this fashion, the histological features and B-cell markers are those of a non-Hodgkin lymphoma. Untreated large cell lymphomas are progressive and rapidly fatal. Usually, however, they respond to combination therapy (multidrug chemotherapy, often combined with the anti-CD 20 antibody rituximab). As opposed to indolent lymphomas, which respond but almost always relapse, most large cell lymphomas are cured with therapy. Exceptions are mantle cell lymphomas and primary central nervous system lymphomas, which are more refractory to therapy.
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