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Flashcards in Heme Lymph CIS Handout Deck (61)
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1

Possible symptoms of CLL

Painless swelling of LNs, often in cervical area, which spontaneously wax and wane but do not disappear

Most pts feel entirely well with no symptoms and diagnosis is made based on routine blood count showing absolute lymphocytosis

5-10% will have B symptoms (fever, weight loss, drenching night sweats, extreme fatigue)

2

Most common abnormal finding on PE of a pt with CLL

LAD — most commonly cervical, supraclavicular, and axillary [described as firm, rounded, discrete, nontender, and freely mobile upon palpation]

3

Second most frequently enlarged organ in CLL

Spleen

[usually painless and nontender to palpation]

4

Besides the common findings of LAD and splenomegaly, what are some other PE findings associated with CLL?

Hepatomegaly

Leukemia cutis (skin is most commonly involved non-lymphoid organ) — usually involves the face and can manifest as macules, papules, plaques, nodules, ulcers, or blisters

Virtually any lymphoid tissue may be enlarged at dx, including Waldeyer’s ring in the pharynx [Note: in contrast to other lymphomas, clinically relevant GI mucosal involvement is rarely seen in CLL. Similarly, meningeal leukemia is unusual at the time of initial presentation]

MGGN has occasionally been described in CLL: paraneoplastic deposition and possibly processing of cryoprecipitating or noncryoprecipitating M-components

5

The most noteworthy lab abnormality found in CLL is lymphocytosis in the peripheral blood and bone marrow. What is the absolute blood lymphocyte threshold for diagnosing CLL?

>5000/microliter [5x10^9/L]



Note: a significant proportion of pts present with counts as high as 100,000/microliter

6

Other than lymphocytosis, what other lab abnormalities are associated with CLL?

Cytopenias — neutropenia, anemia, and thrombocytopenia (usually not severe)

Immunoglobulin abnormalities — hypogammaglobulinemia (may affect IgG, IgA, and/or IgM)

The above findings contribute to increased vulnerability of CLL pts to major bacterial infections

7

What are the implications of cytopenias seen in CLL?

Increased incidence of autoimmune hemolytic anemia (AIHA) — thus the direct antiglobulin (Coombs) test (DAT) may be positive at some time during the course of the disease in up to 35% of cases

Pure red cell aplasia (rare)

Autoimmune thrombocytopenia is suggested when a bone marrow biopsy shows adequate numbers of megakaryocytes

Agranulocytosis (rare)

8

Diagnostic evaluation of a pt suspected of having CLL should include what?

CBC with diff

Exam of peripheral smear

Immunophenotypic analysis (flow cytometry) of circulating lymphocytes

[bone marrow aspirate/bx and LN bx are not required elements of diagnostic workup; chromosomal changes in CLL are not diagnostic features of the disease]

9

Morphology associated with CLL

Peripheral smear shows lymphocytosis (small, mature appearing lymphocytes with dense nucleus)

These PROLYMPHOCYTES usually account for minority of overall lymphocyte population. The smear often contains SMUDGE cells (aka BASKET cells)

10

2 criteria that must be met to make dx of CLL

Absolute B lymphocyte count in peripheral blood >5000/microL with a preponderant population of morphologically mature-appearing small lymphocytes

Demonstration of clonality of the circulating B lymphocytes by flow cytometry of peripheral blood (majority should express extremely low levels of SmIg and either kappa or lambda light chains; expression of B cell associated antigens — CD19, CD20, CD23; and expression of T cell associated antigen CD5

11

What are the prognostic variables on the CURB-65 mortality prediction tool for pts with community-acquired pneumonia?

Confusion
BUN > 20mg/dL
RR >30 breaths/minute
BP (syst <90, diast <60)
Age > 65

[0-1 points tx as outpatient, 2 pts tx as inpatient, >3 pts tx in ICU]

12

The following are genetic features of what neoplastic entity:

Deletion 13q, trisomy 12, deletion 11q, deletion 17p, TCR genes not clonally rearranged

CLL/SLL

13

Absolute increase in number of clonal B cells in peripheral blood does not exceed 5000/microL w/ immunophenotype identical to CLL, and pts have no LAD, organomegaly, cytopenias, or other symptoms

Monoclonal B cell lymphocytosis

14

>55% of circulating lymphocytes are prolymphocytes; bone marrow is infiltrated in an interstitial or nodular pattern by similar cells

Express bright surface IgM +/- IgD and bright CD20 as well as other B cell Ags (CD19, CD22, CD79a, FMC7)

No associated paraproteinemia; TCR genes not rearranged

B cell prolymphocytic leukemia

15

t(11;14)

Mantle cell lymphoma

16

Unlike CLL, most cases of ____ are negative for CD5, express CD11c, CD103, CD123, cyclin D1, and/or annexin A1

HCL

17

Can have a leukemic phase that mimics CLL morphologically with circulating small lymphocytes with irregular or cleaved nuclei. Like CLL, coexpress CD20 and CD5 and do not express CD23 but stain strongly for cyclin D1 and surface membrane Ig

Mantle cell lymphoma

18

Peripheral blood involvement is usually less prominent; circulating malignant cells have plasmacytoid appearance; lacks CD23 expression and stains strongly for surface IgM, CD20, and cytoplasmic Ig

Lymphoplasmacytic lymphoma

19

Guidelines for pneumococcal vaccine in CLL pts (PCV13 and PPSV23)

Give PCV13 followed by PPSV23 at least 8 weeks later

Administer second dose of PPSV23 at least 5 years after the first dose of PPSV23

20

Vaccines that are recommended in immunocompromising conditions such as CLL

Influenza vaccine annually

Tdap then Td every 10 years

HPV (3 doses through age 26)

PCV13 and PPSV23

[meningococcal, Hep A, and Hep B recommended if some other risk factor is present; Hib is recommended for post-HSCT recipients only]

21

Vaccines that are contraindicated in immunocompromising conditions such as CLL

Varicella
Zoster
MMR

22

Common etiologies of community acquired PNA in outpatients

In order of frequency:

Unknown
M.pneumoniae
Respiratory viruses
S.pneumoniae
Chlamydophila pneumoniae
Legionella
Haemophilus influenzae

23

Most common (known) cause of community acquired pneumonia in hospitalized pts

S.pneumoniae

[others include respiratory viruses, legionella, M.pneumoniae, etc.]

24

Biomechanical OMM considerations for PNA pt

Indirect OMT to all somatic dysfunctions — especially cervicals, scalenes, pectorals, ribs, thoracics, diaphragm

25

Resp-circ OMM considerations for PNA pt

Treat zink patterns — suboccipital release, TI release, diaphragm release with vacuum modification

Tapotement/cupping/slapping to break up consolidation (potential relative contraindication pending further investigation of abnormal CBC in CLL pt)

26

Neurologic OMM considerations for PNA pt include chapman’s points, somatic nervous system, and autonomic nervous system.

What are the anterior chapmans points associated with heart/bronchi/esophagus, upper lung, and lower lung?

Heart/bronchi/esophagus = 2nd ICS along SB

Upper lung = 3rd ICS along SB

Lower lung = 4th ICS along SB

27

Neurologic OMM considerations for PNA pt include chapman’s points, somatic nervous system, and autonomic nervous system.

What are the somatic nervous system components that could be addressed?

Cranial considerations — dural tension, tension around jugular foramen — relieve vagus

Paraspinal tension reflecting general neurologic tone in the cervical area

28

Neurologic OMM considerations for PNA pt include chapman’s points, somatic nervous system, and autonomic nervous system.

General ANS can be addressed with CV4. Increased parasympathetic tone may lead to thickening of secretions and relative bronchiole constriction. What are the parasympathetics that could be addressed?

Vagus n. — OA, AA, C2

Tenderpoints

Compression of OM sutures as well as OA joint

29

Neurologic OMM considerations for PNA pt include chapman’s points, somatic nervous system, and autonomic nervous system.

Increased sympathetic tone may lead to bronchiole dilation. What are the sympathetics and motor components that can be addresseed?

Sympathetics: T1-7; direct inhibition; Tender points; Gentle rib raising

Motor: C3-5 (phrenic n. to the diaphragm; irritation caused by decreased excursion and overuse; tenderpoints

30

Met-En-Immune considerations for OMM in PNA pt

OMT using lymphatic pumps has been shown to increase circulating leukocytes reflecting an enhancement of immune response