HEMATOLOGY, ONCOLOGY, ALLERGY,AND IMMUNOLOGYThe tendency of RBCs to stack
in the presence of fibrinogen
causes them to settle faster
and provides the basis for the
erythrocyte sedimentation
rate test.TREATMENT
■ IV fluids—maintain a positive fluid balance
■ Saline diuresis—causes calcium excretion after fluid volume is restored;
may add furosemide to assist in diuresis
■ Bisphosphonates (pamidronate, zoledronate) inhibit bone resportion.
■ Calcitonin inhibits bone resorption and increases calcium excretion.
■ Glucocorticoids have direct cytolytic effect on some tumor cells, inhibit
calcium absorption from intestines, increase calcium excretion.
■ Phosphate binds calcium, but not part of routine ED treatment due to the
possibility of causing calcium-phosphate deposition.
■ Mithramycin decreases bone resorption
■ Dialysis is indicated for patients with renal failure.
Hyperviscosity Syndrome
This syndrome is characterized by sludging and the term is used to describe
decreased perfusion secondary to increased products (paraproteins, RBC,
WBC) in the bloodstream.
CAUSES
■ Waldenstrom macroglobulinemia (increased IgM)
■ Multiple myeloma (increased IgG or IgA)
■ Leukemias with blast transformation
■ Polycythemia vera
SIGNS/SYMPTOMS
■ Blurred vision, headache, fatigue, somnolence, stroke, mesenteric ischemia
DIAGNOSIS
■ Peripheral smear may show rouleaux formation, which describes stacks of
RBCs that form in the presence of increased serum proteins, particularly
fibrinogen and globulins.
■ Increased WBC, Hb, serum proteins
TREATMENT
■ Two unit phlebotomy with replacement with IV fluids
■ Plasmaphoresis: Dysproteinemias
■ Leukaphoresis: Blast transformations
■ Chemotherapy
A 60-year-old male presents with complaints of fever. His temperatures at
home have been running 38.5°C. He has an indwelling catheter in place
that is red and tender. Otherwise, he denies other symptoms and does
not appear toxic. His CBC shows an absolute neutrophil count (ANC) of 400/μL.
What are your next steps in management?
Obtain cultures and start ceftazidime and vancomycin. Remove indwelling
catheter. Also do a careful skin exam and check CXR and urine for alternative
source of infection.