CHAPTER 82 529 Complications of cancer Characteristics of Tissue affected Mechanism of pain pain/comments Pleura and Infi ltration of pleura Well-localized sharp pain peritoneum or peritoneum by provoked by inspiration tumor Non-malignant causes are common (e.g. pulmonary embolism and pneumonia) Visceral pain Pain from deep Pain poorly localized to the structures of chest, affected viscera and may abdomen or pelvis refer to other sites. May be tender to palpation over affected organ Non-malignant causes are common Nerve Compression of Pain may be continuous (e.g. compression nerve by tumor or tumor compression) or pain bone intermittent (e.g. skeletal instability), but only investigation will differentiate the cause Reduced sensation or paresthesiae are common Neuropathic Altered spinal and Unpleasant sensory change pain central (e.g. burning, cold, numb, neurotransmitter stabbing) in the levels caused by distribution of a peripheral nerve damage nerve or nerve root. Often accompanied by hypersensitivity or allodynia (pain on light touch) May involve the sympathetic system and have a vascular distribution accompanied by sympathetic changes (pallor or fl ushing, sweating or absence of sweating) Continued 530 SPECIFIC PROBLEMS: HEMATOLOGY/ONCOLOGY Complications of cancer Characteristics of Tissue affected Mechanism of pain pain/comments Central Spinal cord Spinal pain is usually fi rst nervous compression feature system (p. 339) Motor and sensory signs occur later Sphincter disturbance is a late sign Cerebral metastases Headache on lying fl at, vomiting, drowsiness, focal neurological defi cit TABLE 82.6 Other causes of pain in the patient with cancer Mechanism Comment Chemotherapy Pain may be associated with the infusion of chemotherapy. Peripheral neuropathy and severe mucositis can also occur although these take longer to develop Radiotherapy Can cause infl ammation and ulceration of exposed mucous membranes (e.g. gut, vagina, bladder) Myelopathy may occur following radiation of the cervical and thoracic spinal cord (tends to develop weeks after treatment and may take up to 6 months to resolve) Hormonal therapy Tumor fl are may occur transiently with initiation of luteinizing hormone releasing hormone (LHRH) therapy in patients with prostate cancer Tumor fl are may also occur following hormonal treatment of breast cancer Continued Complications of cancer Mechanism Comment Indirectly related E.g. pulmonary embolism, peptic ulceration, to cancer constipation, infection, pressure sores Other causes E.g. pre-existing arthritis TABLE 82.7 Acute superior vena cava obstruction Element Comment Causes Two-thirds of cases due to cancer: lung cancer (72%); lymphoma (12%); other cancers (16%) One-third of cases due to non-malignant causes, most often thrombosis associated with intravenous catheter or leads of pacemaker/ICD Clinical features Swelling of the face or neck (80%), often with cyanosis or plethora Swelling of the arm (70%) Breathlessness ( 65%) Cough (50%) Distended neck veins and prominent chest wall collateral veins Diagnosis Chest X-ray usually abnormal in cancer-related SVC obstruction, with mediastinal widening (in two-thirds) and pleural effusion (in one-quarter). CT with contrast for defi nitive diagnosis, or MRI if contrast administration contraindicated Management of Seek expert advice SVC obstruction Obtain tissue for histological/cytological diagnosis due to cancer Corticosteroids if suspected lymphoma or thymoma (as steroid-responsive) Radiotherapy/chemotherapy as appropriate to cancer type Stent placement if severe symptoms requiring urgent relief of obstruction CT, computed tomography; ICD, implantable cardioverter-defi brillator; MRI, magnetic resonance imaging; SVC, superior vena cava. 532 SPECIFIC PROBLEMS: HEMATOLOGY/ONCOLOGY Complications of cancer Further reading Halfdanarson TR, et al. Oncologic emergencies: diagnosis and treatement. Mayo Clinic Proc 2006; 81: 835–48. Wilson LD, et al. Superior vena cava syndrome with malignant causes. N Engl J Med 2007; 356: 1862–9. See also links in Symptom Management, Cancer Specialist Library, NHS National Library for Health (http://www.library.nhs.uk/cancer/SearchResults.aspx?catID=12286). Miscellaneous Acute medical problems in HIV-positive patients 83 Acute medical problems in HIV-positive patients 535 HIV-positive patient with respiratory symptoms Seek advice from chest/infectious diseases physician Key observations Focused assessment (Tables 83.1, 83.2) Urgent investigation (Table 83.3) Chest X-ray Normal Sputum examination Abnormal Sputum examination No sputum/pathogen not identified Further investigation for Pneumocystis carinii pneumonia (PCP) (e.g. CT, exercise oximetry) Positive Bronchoscopy with bronchoalveolar lavage (BAL) Further management depending on results of BAL Negative Observation Pathogen identified Treat No sputum/pathogen not identified Treat likely diagnosis (Table 83.2) 536 SPECIFIC PROBLEMS: MISCELLANEOUS Acute medical problems in HIV-positive patients TABLE 83.1 Respiratory symptoms in the HIV-positive patient CD4 T cell count (× 10 6 /L) >500 200–500 <200 Usual causes Usual causes Usual causes Mycobacterium M. tuberculosis Pneumocystis carinii (jiroveci) tuberculosis infection pneumonia infection M. tuberculosis infection M. avium intracellulare infection Cytomegalovirus pneumonitis Fungal pneumonia Kaposi sarcoma ALERT Seek expert advice from an infectious diseases physician on the management of acute medical problems in the HIV-positive patient. TABLE 83.2 Diagnostic clues in the HIV-positive patient with respiratory symptoms. Diagnosis Clinical features Chest X-ray features Pneumocystis Dyspnea Diffuse bilateral carinii (jiroveci ) Dry cough interstitial or alveolar pneumonia Lungs clear, or sparse shadowing (PCP) basal crackles Lobar consolidation rare Fever Pleural effusion rare See Table 83.4 Pneumothorax may occur See Table 83.4 Continued CHAPTER 83 537 Acute medical problems in HIV-positive patients Diagnosis Clinical features Chest X-ray features Mycobacterium Cough More often typical of tuberculosis Hemoptysis tuberculosis if CD4 infection Fever count is >200: multiple areas of consolidation, often with cavitation, in one or both upper lobes Mycobacterium Cough Often normal avium Dyspnea intracellulare Fever infection Bacterial Commoner in smokers Focal consolidation pneumonia Productive cough (p. 268) Focal signs Fever Cytomegalovirus Clinically Diffuse bilateral pneumonitis indistinguishable interstitial shadowing from PCP (dual infection may occur) Fungal Fever Diffuse bilateral pneumonia Cough interstitial shadowing Weight loss in ∼50% Systemic features of Focal shadowing, fungal infection nodules, cavities, may be present pleural effusion and (skin lesions, hilar adenopathy may lymphadenopathy, be seen hepatosplenomegaly) Continued 538 SPECIFIC PROBLEMS: MISCELLANEOUS Acute medical problems in HIV-positive patients Diagnosis Clinical features Chest X-ray features Kaposi sarcoma No fever Diffuse bilateral Dyspnea interstitial shadowing, More common in more nodular than homosexual men PCP and Africans than IV May be unilateral and drug users associated with hilar May be associated with adenopathy cutaneous Kaposi Pleural effusion strongly sarcoma suggestive TABLE 83.3 Urgent investigation of the HIV-positive patient with respiratory symptoms • Chest X-ray • Arterial blood gases • Full blood count and fi lm • CD4 T cell count and viral load • Blood culture (positive in most patients with Mycobacterium avium intracellulare infection: use specifi c myobacterial culture bottles) • Blood glucose • Creatinine, sodium and potassium • Liver function tests • Lactate dehydrogenase (raised in Pneumocystis carinii ( jiroveci) pneumonia) • Expectorated sputum if available for Gram and Ziehl–Nielsen stain and culture • Induced sputum (using hypertonic saline via nebulizer) for staining for P. carinii ( jiroveci) CHAPTER 83 539 Acute medical problems in HIV-positive patients TABLE 83.4 Pneumocystis carinii ( jiroveci ) pneumonia (PCP): diagnosis and management Element Comment Patients at risk Newly diagnosed HIV infection with advanced disease (CD4 count <200) Patients with previous PCP or CD4 count <200 who are not taking prophylaxis Clinical features Subacute onset Fever (∼90%) Cough (∼95%), usually non-productive Progressive breathlessness (∼95%) Tachypnea (∼60%) Chest examination normal in ∼50% Chest X-ray Initially normal in up to 25% features Commonest abnormalities are diffuse bilateral interstitial or alveolar shadowing Lobar consolidation rare Pleural effusion rare Pneumothorax may occur Induced sputum Staining of induced sputum for P. carinii (jiroveci) trophic forms and cysts Specifi city ∼100%, sensitivity 50–90% Bronchoscopy Indicated if PCP is suspected but induced sputum with is non-diagnostic or cannot be done bronchoalveolar Specifi city ∼100%, sensitivity ∼80–90% lavage Antimicrobial First choice: co-trimoxazole PO or IV for 21 days. therapy Causes hemolysis in glucose-6-phosphate dehydrogenase-defi cient patients (African/ Mediterranean). Other side effects include nausea, vomiting, fever, rash, marrow suppression and raised transaminases Alternative regimens: primaquine + clindamycin; atovaquone; pentamidine Continued [...]... AST, aspartate aminotransferase; LDH, lactate dehydrogenase Further reading Davies S Amniotic fluid embolus: a review of the literature Can J Anaesth 2001; 48: 88 98 Duley L, et al Management of pre-eclampsia BMJ 2006; 332: 463–8 James PR, Nelson-Piercy C Management of hypertension before, during, and after pregnancy Heart 2004; 90 : 1 499 –504 Moore J, Baldisseri MR Amniotic fluid embolism Crit Care Med... 2 Management of agitated or aggressive behavior Action Comment Assessment of patient Obtain background information: age, psychiatric and medical diagnoses, current medication Exclude/treat hypoglycemia (p 423) If restraint of the patient may be needed, for the safety of the patient and other patients/staff, call for help from trained staff Continued CH AP TE R 86 557 Comment Behavioral measures and... Lassa fever, visceral leishmaniasis Hepatomegaly Amoebiasis, malaria, typhoid, hepatitis, leptospirosis Splenomegaly Malaria, relapsing fever, trypanosomiasis, typhoid, brucellosis, kala-azar, typhus, dengue fever Eschar (painless ulcer with black center and erythematous margin) Typhus, borreliosis, Crimean-Congo hemorrhagic fever Hemorrhage Lassa, Marburg or Ebola viruses; Crimean-Congo hemorrhagic... 3 Headache in pregnancy/peripartum period • • • • Pre-eclampsia/eclampsia (Table 85.4) Hemorrhagic stroke Cerebral venous sinus thrombosis Migraine 551 Acute medical problems in pregnancy and peripartum • Pre-eclampsia/eclampsia (Table 85.4) • Pulmonary edema due to pre-existing cardiac disease (e.g mitral stenosis, aortic stenosis) • Pulmonary edema due to peripartum cardiomyopathy • Tocolytic-induced... the management of a patient admitted with self poisoning or deliberate self harm who Make sure to document all three in the notes when assessing competence Arrange for a second doctor to assess and document competence Factors that can affect competence: Alcohol and drugs Severity of the overdose Organic disease If the patient attempts to leave while waiting, persuade him or her to stay If the patient... cardiomyopathy Alcoholic hepatitis (p 404) Acute pancreatitis (p 406) Cirrhosis Variceal bleeding Alcoholic gastritis Poor diet with consequent vitamin deficiencies Myopathy Fractures Macrocytosis Anemia Thrombocytopenia Leucopenia Liver and pancreas Alimentary tract Musculoskeletal Hematological T A B L E 87 3 Management of alcohol withdrawal syndrome and Wernicke encephalopathy Problem Features Management Alcohol... medical treatment only Continue to try to gain consent The patient can be detained under the Mental Health Act and if the overdose is a consequence of mental disorder, essential medical treatment may be given (under guidance of senior psychiatrist) Psychiatric problems in acute medicine refuses treatment and is at risk of harm From Hassan, T.B et al BMJ 199 9; 3 19: 107 9 FIGUR E 8 6 1 Algorithm for the management. .. (louse-borne, flea-borne) • Plague • Paratyphoid • Viral hemorrhagic fever (Lassa, Marburg, Ebola) 546 S P E C IFIC PROBLEMS: MI SCELLANEOUS T A B L E 84 3 Urgent investigation of the patient with a febrile illness Fever on return from abroad after travel abroad • Full blood count • Blood film for malarial parasites if travel to or through an endemic area; the intensity of the parasitemia is variable in malaria... on leaving, try to ensure that the patient is with relatives/friends Inform the patient's general practitioner (he/she may be able to help) Senior Emergency Dept doctor must reassess the patient's capacity for consent/refusal of treatment Psychiatrist assesses the patient The patient is not detainable under Mental Health Act ( 198 3) Psychiatrist may advise on the patient's capacity Seek a psychiatric... nerve palsy (unable to abduct the eye) Ataxia with wide-based gait; may be unable to stand or walk Treat with IV thiamine (Pabrinex IV high-potency injection, containing thiamine 250 mg per 10 ml (2 ampoules): one pair of ampoules 12-hourly for 5–7 days, given slowly over 10 min (may cause anaphylaxis), followed by oral thiamine CH AP TE R 87 565 Further reading Brathen G, et al European Federation of . Lassa fever, visceral leishmaniasis Hepatomegaly Amoebiasis, malaria, typhoid, hepatitis, leptospirosis Splenomegaly Malaria, relapsing fever, trypanosomiasis, typhoid, brucellosis, kala-azar,. not necessary to give Fansidar, doxycycline or clindamycin after treatment with Malarone or Riamet TABLE 84.6 Falciparum malaria: management of complications Complication Comment /management Hypotension. investigation of the patient with a febrile illness after travel abroad • Full blood count • Blood fi lm for malarial parasites if travel to or through an endemic area; the intensity of the parasitemia