Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers

Chat recap of the #ClinicalPearls #VirtualMorningReport

June 26th Day 83: clinicalproblemsolving.com/morning-report…

w/ Neha Teekappanavar @DxRxEdu @rabihmgeha

Case Overview by @LindseyShipley8

Let's start with an initial problem representation:

A 52 y/o F presents with 2 months of fatigue, 3 wks of mid back pain, foamy urine, hypersalivation, and swelling in her ankle and face

Enter ITAMED:

would look for systemic symptoms like weight loss, night sweats

Back pain age over 50 is a red flag to image

frothy urine...nephrotic?

foamy urine can indicate proteinuria although non-specific

clinical significance of foamy urine?ncbi.nlm.nih.gov/pmc/articles/P…

In the study cited above, Of the 72 patients w/ foamy urine, 22.2% had overt proteinuria & that dm, poor renal function (🔼Cr, BUN, 🔽eGFR), 🔼serum phosphate, &🔼 serum glucose were associated w/ overt proteinuria

I don’t think anybody has an illness script for increased saliva

sialorrhea. is there a toxidrome? cholinergic

hypersalivation from rabies ncbi.nlm.nih.gov/pmc/articles/P…

the ankle and facial swelling could be the result of a kidney injury. Similar to PSGN

multiple myeloma with proteinuria on back of someones mind as it can cause nephrotic syndrome

On PE we also need to distinguish from bony tenderness vs paraspinal muscle pain for her midline tenderness

if it’s truly proteinuria would be helpful to do age appropriate cancer screening, hepatitis test for membranous nephropathy

obesity, HIV, IVDU are risk factors for FSGS

Thrombosis from nephrotic syndrome can cause back pain

Talking of thrombosis it can be PNH causing thrombosis in unlikely places

Thromboembolism is the MCC of mortality in patients w/ PNH & accounts for approx 40%-67% of deaths ashpublications.org/blood/article/…

Is the hypercalcemia a PIVOT POINT

persistent hyperCa can cause polyuria (nephrogenic DI)

Hypercalcemia = bone pain and nephrotic syndrome?

struggling to fit in the salivation, feel like that may be related somehow.. other than large mass in the neck causing swallowing obstruc

Hypercalcemia: Stones bones, moans and psychiatric overtones

Check out the @runthelistpod handout on HyperCa, runthelistpodcast.com/s/RTL_Hypercal…

PTH is also know as the phosphate trashing hormone

Could this be X-linked hypophosphatemic rickets, rarediseases.info.nih.gov/diseases/12943…

We are still stuck on the hypersalivation...Noise?

as any invasion of salivary glands by amyloid or inflammation should cause hyposalivation

Paging Dr. Hickam!!!

protein to creatinine ratio of 0.5

Urine protein Cr ratio is helpful to see if missing BJ proteins

The urine protein to cr ratio OVERestimates

no nephrotic syndrome

And she has a very elevated PTH, (PTH Dependent) likely causing the hypercalcemia

Diagnosis and management of parathyroid cancer, nature.com/articles/nrend…

whenever you look for MM order spep AND free light chains (nowadays FLC replaced UPEP)

osteitis fibrosa cystica is so rare these days as it is seen in the setting of long-standing hyperPTH

is a skeletal disorder caused by a surplus of PTH from overactive parathyroid gland

Osteitis fibrosa cystica—a forgotten radiological feature of primary hyperparathyroidism, ncbi.nlm.nih.gov/pmc/articles/P…

the MASSIVE decline in her kidney function is due to light chains

this is called protein cast nephropathy, “myeloma kidney,” ncbi.nlm.nih.gov/pmc/articles/P…

Her US thyroid w/ possible adenine & subcm cystic nodule; sestamibi with no spot uptake, but did show multiple osteopathic lesions in clavicle, scapulae, mandibles

brown tumors can occur in clavicles, distally more typical

Makes sense, her Ca is just too high for pure hyperpara

Usually primary hyperparathyroidism does not cause calcium greater than 14

She had no Gamma Gap...

u might not always see a gamma gap especially when it’s been present for a prolonged period of time

One thing to think about with serum light chains is the often in kidney disease you can get a mildly elevated kappa to lambda ratio. Usually, a ratio >3.5 in renal insufficiency is significant though.

Final Dx: Parathyroid adenoma, light chain myeloma & primary hyperparathyroid

When thinking about hyperCa, usually the mechanism of causing renal disease is a diuresis leading to dehydration, the edema did not fit (could consider the development of an ATN).

It is always good to further investigate when all the pieces do not fit

https://twitter.com/AnnKumfer/status/1277369038671417344

SPEP neg can miss IgE and IgG & non secretory types

SPEP/UPEP/Free light chains will dx 99%

50% of MM w/ renal failure will recover

Teaching points by @sukritibanthiya: clinicalproblemsolving.com/wp-content/upl…

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