Creatine Kinase - Causes of Elevated CK Levels
Acute CK Elevation (Pain > Weakness):
• RHABDOMYOLYSIS
- Drugs: cocaine, amphetamines, alcohol
- Medications: statins, fibrates, colchicine, daptomycin
- Illness: viral (COVID19, CMV/EBV, HIV), clostridial spp, mycoplasma, staph, strep)
- Seizures: Trauma, burns, hyperthermia, immobility
• Critical Illness Myopathy (ICU, steroids, mechanical ventilation)
• Myocardial infarction, Acute renal injury, Strenuous exercise
Subacute to Chronic Causes (Weakness > Pain):
• PROXIMAL MUSCLE WEAKNESS
- Endocrine: Hypo/hyperthyroidism, acromegaly
- Electrolytes: hypo- phos, kalemia, calcemia, natremia
- Muscular dystrophy
- Metabolic Myopathies
- Neuromuscular disorders
- Vit D/E deficiency
- Medications- Statins, fibrates, colchicine, daptomycin
- Chronic Illness: HIV, Trichinella, toxoplasmosis
- Inflammatory myopathy: dermatomyositis, polymyositis, necrotizing myopathy
- Autoimmune: mixed connective tissue disorder, SLE
• PROXIMAL AND DISTA: Inclusion body myositis
• ASYMPTOMATIC: Macro CK
Ann Marie Kumfer @AnnKumfer
#Creatine #Kinase #Elevated #CK #differential #diagnosis #rhabdomyolysis
Multiple Myeloma and Monoclonal Gammopathies
C - HyperCalcemia- calcium > 11 mg/dL / >1 mg/dL the ULN
R - Renal disease - Cr >2 mg/dL or CC < 40 ml/min
A - Anemia- Hemoglobin < 10 g/dL or <2 g/dl LLN
B - Bony lesions
+1 or more:
• Clonal bone marrow plasma cell percentage ≥60%
• Involved: uninvolved serum free light chain ratio ≥100
• >1 focal lesions on MRI studies
Look for gamma gap (total protein - albumin) ≥ 4 to identify hypergammaglobulinemia; SPEP determines if this is is monoclonal or polyclonal.
Causes of false- negative SPEP:
• Non-secretory MM (1-2% of MM), light chain deposition disease, and amyloidosis
Other causes of a monoclonal M spike:
• CML, B and T cell lymphoproliferative diseases, CML, amyloidosis, solitary plasmacytoma, POEMs syndrome, Castleman's, Waldenström's macroglobulinemia, and autoimmune diseases.
Dr. Ann Marie Kumfer @AnnKumfer
#MultipleMyeloma #Monoclonal #Gammopathies #MGUS #diagnosis #hematology #oncology
Hypokalemia - Differential Diagnosis Algorithm
Extra-renal Losses:
• Normal Acid-Base: Low intake
• Metabolic acidosis: Gl tract loss (Diarrhea)
Renal Losses:
• Metabolic acidosis: Proximal and distal RTA, Ureterosigmoidoscopy
• HTN, Low Aldosterone: Liddle's Syndrome, Licorice, Carbenoxolone, SAME, Cushing Syndrome
• HTN, High Aldosterone: Malignant HTN, Renovascular HTN, Renin secreting tumor, Primary hyperaldosteronism
• HTN Absent: Loop and thiazide diuretics, Bartter syndrome, Gitelman syndrom, Vomiting, Non-reabsorbable anions
Dr Priti Meena @priti899
#Hypokalemia #Differential #Diagnosis #Algorithm #causes #potassium #low #nephrology
Salicylate Toxicity - Diagnosis and Management
Consider if:
1) Patient is hot and altered
2) You see tachypnea with no respiratory cause
3) Labs show anion-gap metabolic acidosis
4) Presentation seems like DKA, sepsis, PNA, meningitis
5) History of acute or chronic ingestion/exposure
Symptoms: Nausea, Vomiting, Tinnitus, Hearing loss, Dizziness, Altered, Seizure, Coma
Exam: Tachypnea, Tachycardia, Elevated temp, Diaphoresis, Pulmonary edema, Shock
Labs: Anion-Gap Metabolic Acidosis, Respiratory Alkalosis, High Lactate, Low Potassium, Low Glucose, Salicylate level
- Toxic Salicylate Level: 150mg/kg
Management:
1) Resuscitation
2) Urine pH > 7.5 with Alkalinzation
3) Glucose > 4.5 mmol/L
4) K > 4.5 mmol/L
5) Dialysis
By Sarah Foohey @SarahFoohey
#Salicylate #Aspirin #Toxicity #Toxicology #diagnosis #management #Treatment
Bleeding manifestations
Petechiae are small, flat, red, discrete areas of skin bleeding that are typically <2 mm in diameter. They are non-blanching, nonpalpable, and occur in dependent areas of the body Purpura results from coalesced petechiae. Purpura due to vasculitis is usually palpable and may be pruritic, and the distribution does not follow dependent areas. Wet purpura is the most predictive of serious bleeding in individuals with thrombocytopenia. Bruise (also called ecchymosis) is caused by the subcutaneous accumulation of extravasated blood. The skin is flat, and the color evolves over time from purplish blue to reddish brown to greenish-yellow, reflecting the metabolism (breakdown) of hemoglobin to biliverdin and bilirubin. Hematoma is a collection of blood in the extravascular space. Hematomas and hemarthroses (joint bleeding) are typical of coagulation factor deficiencies.
Von Willebrand factor
Glycoprotein
Synthesized in endothelial cells & megakaryocytes.
Excessive bruising & prolonged bleeding
Levels vary with stress; increase with estrogens, vasopressin, GH & adrenergic stimuli.
Repeat tests at > 2 weeks
Type O blood normally has the lowest levels
Platelet levels tend to be normal, PT should be normal.
Diagnosis
VWF antigen level VWF:Ag (Quantity of VWF present in plasma; <50 are considered to be low)
VWF ristocetin cofactor assay (Efficacy of this plasma VWF in its ability to bind platelets in the presence of antibiotic ristocetin).
Measurement of coagulation factor VIII (FVIII:C)
Ratio of VWF:RCo/VWF:Ag (differentiate VWD type 1 and 2)
#Petechiae #Purpura #Bruise #ecchymosis #thrombocytopenia #Hematomas #blanching
Satyendra Dhar MD, @DharSaty
Approach to Thyroid Function Tests in the Evaluation of Hyperthyroidism
• Low TSH, Low normal T4 → Possibly Central Hypothyroidism. unlikely subclinical hyperthyroidism.
• Low TSH, normal T4 +/- T3 → Subclinical Hyperthyroidism: Work-up similar to hyperthyroidism as below. Can repeat labs 6 weeks after the resolution of pregnancy, critical illness, and dopamine agonists/octreotide.
• Low TSH, high T4 +/- T3 → Primary Hyperthyroidism
→ Signs of symmetrically enlarged thyroid & ophthalmopathy → Graves' Disease → Confirm with TRAb
→ Radioactive Iodine Uptake & Scan
• High or normal TSH, high T4 +/- T3 → Central (secondary) Hyperthyroidism → MRI Pituitary
- Dr. Claire Brickson @crbricks
#Hyperthyroidism #algorithm #diagnosis #endocrinology #TFTs #TSH #Interpretation
