Makindo Medical Notes

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Spinal Cord Compression

Clinical Presentation:

• Back pain, often worse at night and aggravated by coughing or straining.
• Neurological deficits including weakness, sensory loss, and autonomic dysfunction (e.g., bowel or bladder incontinence).
• Common in cancers with vertebral metastases (e.g., breast, lung, prostate).

Diagnostic Tests:

• MRI of the spine is the imaging modality of choice to assess the extent of compression.
• CT scan may be used if MRI is contraindicated.
• Neurological examination to assess the level and severity of spinal cord involvement.

Treatment:

• Immediate corticosteroids (e.g., dexamethasone) to reduce swelling and prevent further neurological damage.
• Emergency radiation therapy or surgery depending on the severity and location of the compression.
• Pain management and supportive care, including physical therapy for rehabilitation.
• Consideration of oncological treatment (e.g., chemotherapy) for the underlying malignancy.

Superior Vena Cava (SVC) Syndrome

Clinical Presentation:

• Facial swelling, neck vein distension, and upper extremity swelling.
• Dyspnoea, cough, hoarseness, and headache, often worse when bending forward or lying down.
• Commonly associated with lung cancer, lymphoma, or metastatic tumours compressing the SVC.

Diagnostic Tests:

• CT scan of the chest to identify the site of obstruction and evaluate the extent of disease.
• Chest X-ray may show widening of the mediastinum or pleural effusion.
• Venography or MRI may be used in unclear cases to assess the extent of SVC involvement.

Treatment:

• Elevate the head of the bed and administer oxygen for symptomatic relief.
• Corticosteroids and diuretics to reduce swelling.
• Radiation therapy or chemotherapy to shrink the tumour causing the obstruction.
• Stent placement in the SVC may be considered in severe or refractory cases.

Tumour Lysis Syndrome (TLS)

Clinical Presentation:

• Fatigue, nausea, vomiting, and muscle cramps.
• Signs of acute kidney injury, such as oliguria or anuria.
• Occurs after the initiation of chemotherapy in patients with high tumour burden (e.g., leukaemias, lymphomas).

Diagnostic Tests:

• Laboratory findings include hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.
• Elevated serum creatinine and blood urea nitrogen (BUN) indicating renal impairment.
• Monitor electrolytes, renal function, and uric acid levels frequently after starting chemotherapy.

Treatment:

• Aggressive IV hydration to promote renal excretion of electrolytes and uric acid.
• Allopurinol or rasburicase to prevent or treat hyperuricemia.
• Management of hyperkalemia, hyperphosphatemia, and hypocalcemia with appropriate medications (e.g., insulin, calcium gluconate).
• Dialysis may be necessary in severe cases with refractory electrolyte imbalances or renal failure.

Hypercalcemia of Malignancy

Clinical Presentation:

• Nausea, vomiting, constipation, and polyuria.
• Fatigue, weakness, confusion, and possible coma in severe cases.
• Commonly associated with cancers such as breast cancer, lung cancer, and multiple myeloma.

Diagnostic Tests:

• Elevated serum calcium levels (usually >12 mg/dL).
• Low or undetectable parathyroid hormone (PTH) levels.
• ECG may show shortened QT interval and other signs of hypercalcemia.

Treatment:

• Aggressive IV hydration with normal saline to enhance renal calcium excretion.
• Bisphosphonates (e.g., zoledronic acid, pamidronate) to inhibit bone resorption.
• Calcitonin may be used for rapid but short-term reduction of calcium levels.
• Treat the underlying malignancy to prevent recurrence of hypercalcemia.

Neutropenic Fever

Clinical Presentation:

• Fever (≥38.3°C or ≥38.0°C for more than one hour) in a patient with neutropenia (absolute neutrophil count <500/µL).
• Malaise, chills, and signs of infection, which may be subtle or absent due to neutropenia.
• Often occurs after chemotherapy in patients with hematological malignancies or solid tumours.

Diagnostic Tests:

• Complete blood count showing neutropenia.
• Blood cultures, urine cultures, and chest X-ray to identify potential sources of infection.
• Additional cultures (e.g., from central lines, wounds) based on clinical suspicion.

Treatment:

• Immediate empirical broad-spectrum antibiotics (e.g., piperacillin-tazobactam, cefepime) initiated within 1 hour of presentation.
• Consider antifungal therapy if fever persists after 4-7 days of antibiotics and no source is identified.
• Granulocyte colony-stimulating factor (G-CSF) may be used to shorten the duration of neutropenia.
• Close monitoring for signs of sepsis and organ dysfunction, with supportive care as needed.

Pericardial Effusion with Cardiac Tamponade

Clinical Presentation:

• Dyspnoea, chest pain, and orthopnea.
• Beck's triad: hypotension, muffled heart sounds, and jugular venous distension.
• May occur due to metastatic involvement of the pericardium, particularly in lung or breast cancer.

Diagnostic Tests:

• Echocardiography showing pericardial effusion with signs of tamponade (e.g., diastolic collapse of the right ventricle).
• Chest X-ray may show an enlarged cardiac silhouette.
• ECG may show low voltage QRS complexes or electrical alternans.

Treatment:

• Immediate pericardiocentesis to relieve pressure on the heart.
• IV fluids to maintain blood pressure until definitive treatment.
• Radiation therapy or chemotherapy may be needed to address the underlying malignancy causing the effusion.
• Consider a pericardial window or pericardiectomy for recurrent cases.

Septic Shock in Oncology Patients

Clinical Presentation:

• Fever, chills, and signs of infection, such as cough, dysuria, or cellulitis.
• Hypotension, tachycardia, and altered mental status indicating progression to septic shock.
• Commonly associated with immunosuppression due to chemotherapy or hematological malignancies.

Diagnostic Tests:

• Blood cultures, urine cultures, and other relevant cultures before starting antibiotics.
• Serum lactate levels elevated, indicating tissue hypoperfusion.
• Complete blood count (CBC), electrolytes, renal and liver function tests to assess the severity of the shock.

Treatment:

• Early goal-directed therapy with IV fluids, broad-spectrum antibiotics, and vasopressors (e.g., norepinephrine) if needed.
• Source control, such as drainage of abscesses or removal of infected devices.
• Monitoring for complications, including organ dysfunction and disseminated intravascular coagulation (DIC).
• Supportive care in an ICU setting for severe cases.

Malignant Pleural Effusion

Clinical Presentation:

• Dyspnoea, chest pain, and cough.
• Decreased breath sounds, dullness to percussion, and reduced chest expansion on the affected side.
• Commonly associated with lung cancer, breast cancer, and lymphoma.

Diagnostic Tests:

• Chest X-ray or ultrasound showing fluid in the pleural space.
• CT scan of the chest to evaluate the extent of disease and assess for lung involvement.
• Thoracentesis for pleural fluid analysis, including cytology to confirm malignancy.

Treatment:

• Therapeutic thoracentesis to relieve symptoms and improve breathing.
• Chemical pleurodesis (e.g., talc) to prevent recurrence of the effusion.
• Indwelling pleural catheter for recurrent or symptomatic effusions.
• Treat the underlying malignancy with chemotherapy, radiation, or targeted therapy.