Hey #MedTwitter 👋🏼

A bit about SMUDGE CELLS today!

Also called smear cells because they were initially thought to be artifacts of smear production!

Also called Gumpretch cells after Dr. Gumpretch who first described them in the 1800's

But there's more 👇🏼

#MedTwitter Where do you see them?

Many conditions, but it is almost always seen in patients with Chronic Lymphocytic Leukemia (CLL) 👇🏼

#MedTwitter

As a physician I'm sure you've seen patients with ITP!

Let's start by calling it IMMUNE thrombocytopenia instead of IDIOPATHIC thrombocytopenia.

The P stood for Purpura in the past. Not anymore!

T= Thrombocytopenia = <100,000 platelets

#MedTwitter
1/20 ITP comes in 2 flavours:

•PRIMARY
and
•SECONDARY

SECONDARY TO WHAT?
Long list of possible causes, autoimmune disease, HIV, HepC, drugs etc

#MedTwitter

2/20

Hey #MedStudentTwitter 👋🏼

Do you know what this image shows?

Obviously you do !!

If not, read this short thread 👇🏻

#MedTwitter

1/6 Yeah, those are hemighost cells !

That's a hallmark of severe oxidative damage to red cells. Most often seen in G6PD deficient individuals!

I say most often because it can happen in patients with normal G6PD levels when the oxidative damage is severe 😭

#MedTwitter
2/6

An easy way to remember serum protein electrophoresis for #MedstudentTwitter !

In myeloma, the thumb goes ⤴️ and the pinky finger goes ⤵️

To know more than this, follow along 👇🏼

#MedTwitter

1/16 Now let's see what each spike represents!

α1 =α1 antitrypsin +others (small amount)

α1 antitrypsin (AT) is an ACUTE PHASE REACTANT, so it'll ⤴️in INFLAMMATION

Obviously, α1 is⤵️in α1 AT deficiency!

It's quite simple, isn't it?

Wait, why is α2 ⤴️ in acute inflammation🤔

2/16

📢📢 𝐍𝐄𝐖 𝐓𝐇𝐑𝐄𝐀𝐃 🧵

This is for everyone who uses 𝙘𝙮𝙘𝙡𝙤𝙨𝙥𝙤𝙧𝙞𝙣𝙚, so I'm guessing a lot of people would read this short thread !

It's every transplanter's friend; kidney/🫀/ liver/ BMT 💪

Follow along to learn more 👇

1/20

#MedTwitter Let's roll back time 🔙 to the 1960's 😍

@thebeatles, @pinkfloyd and @ledzeppelin were ruling the charts🤘

Those were good days as far as music was concerned 🎶

Not so good for transplants!

There weren't many immunosuppressive drugs available back then😭

#MedTwitter

2/20

Hey #medicine residents !!

Time to talk about EOSINOPHILS today. Not as common a consult as thrombocytopenia and anemia but important nonetheless.

A short 🧵 to touch upon all things eosinophilia 👇🏻

#MedTwitter Before we go any further, it's important to know this

🩸Eosinophil ≥ 500 is ABNORMAL

Eosinophil is a predominantly tissue dwelling cell so 🩸 eosinophil DON'T correlate with tissue damage 🤷‍♂️

We see a few patients with ⤴️⤴️Eos and no 🫀🫁 injury !!

A thread of some of my #MedEd threads !!

#MedTwitter This one's about my approach to a consult for thrombocytopenia 👇🏻

https://twitter.com/nihardesai7/status/1587702610038968320?t=LSp3UWci_by6Mh1JCqWXyw&s=19

#MedTwitter

Hey #medicine residents !!

PLEASE TRANSFUSE BLOOD PRODUCTS JUDICIOUSLY 🙏🏻

Not every patient with anemia needs blood and not is blood transfusion free of complications.

I'll list out a few TRANSFUSION REACTIONS in case you'll have forgotten about them 👇🏻

#MedTwitter

1/10 Let's start w/ TACO🌮

This isn't the good Mexican 🌮 we love🤣

This is pulmonary oedema resulting from overzealous transfusion🤷‍♂️

Risk factors: patients who can't handle fluids we'll, i.e. patients w/ kidney,heart disease etc

Totally avoidable complication🙏🏻

#MedTwitter

2/10

What does the 𝐖𝐀𝐑𝐅 in warfarin stand for??

Any ideas?

This is an interesting thread, let's dive into the history of one of the most widely used anticoagulants 👇🏻

#MedTwitter Let's roll back time, we are in the 1930s in 🇺🇲, the great depression is at its peak and American farmers are losing their cattle 😭

How ??

Somehow the 🐄🐮 are developing fatal internal hemorrhages 😭😭

No one knew why !!

#MedTwitter

You are a young #medicine resident !!

35/♀️/ wheeled in with 1 e/o seizure f/b loss of consciousness😮

Urgent CT👇🏻

Husband reveals she was on blood thinners after her ♥️ surgery, 5 yrs ago 😱

How do you manage this patient?

Read this thread to know more 👇🏻

#MedTwitter

1/12 Yes, the CT shows a large hematoma

The patient was most likely on a vitamin K antagonist (VKA) post her prosthetic valve surgery!

The labs are back, she has also started to 🩸 through Foley's catheter😭

•CBC: 8/5600/201k
•INR: 8.8
•aPTT: 32s (control 29s)

#MedTwitter

2/12

You are a young #medicine resident in a busy emergency when a 26/♂️ walks in with 👇🏻

C/o cough and respiratory distress + facial swelling x 7days. He is unable to sleep as the symptoms ⤴️ on lying down 😮

What do you do next?

You read this thread👇🏻

#medtwitter

1/18 You immediately know what's going on, you ask for an urgent chest imaging. Only a chest Xray is available and shows 👇🏻

Damnnnnn 😮😮😮

What's that ??

#MedTwitter

2/18

You are a young #medicine resident!

You are working in a heavy emergency when:
23,♂️,p/w acute breathlessness
You check his SpO2, it's👇🏻

You are worried and start him on supplemental 02, but he remains hypoxic😭

Read on for the diagnosis and a brief review!

1/20

#MedTwitter Let's start with the causes of hypoxic that don't respond to supplemental oxygen !

🔸R➡️L cardiac shunts
🔸Methemoglobinemia
🔸Sulfmethemoglobinemia

The ABG that you sent is back!!

It shows a normal Pa02 but your pulse oximeter is still reading 85% 🤷‍♂️

2/20
#MedTwitter

As a #medicine resident you'll come across 👇🏻 scenario often.

Your #surgery colleagues want you to opine on the type and duration of ANTICOAGULATION and also want to know why it occured in the first place🤷‍♂️

Let's dig deeper 👇🏻

1/24

#MedTwitter #DVT Yeah, this is obviously a Deep Vein Thrombosis (DVT) !

It's fairly common, develops in about 1/1000 people 😮

Remember, DVT+PE = VTE

PE= pulm embolism
VTE= venous thromboembolism

⭐1/3 DVT develop PE⭐

The PE is what can lead to mortality!
Preventing PE is IMPORTANT 🙏🏻

2/24

Hey #medicine residents !!

Let's talk a bit about #mucormycosis today, the monster fungus 😡

Horrible infection w/ an unreasonably high mortality (40-80%) 😭

Risk factors:
🔸DM
🔸Neutropenia
🔸Post-HSCT

DM- Rhino-orbito-cerebral mucor
Neutropenia- Pulmonary mucor

#MedTwitter The disease is caused by fungi of the order "MUCORALES"

This includes rhizopus/mucor/licthemia/cunninghemela species 😮

DON'T WORRY species identification doesn't change treatment so we don't need to get to that 🙏🏻

#MedTwitter

If you are a #medicine resident you will be called by your colleague to consult on this topic 👇🏻

**𝐇𝐞𝐩𝐚𝐫𝐢𝐧 𝐈𝐧𝐝𝐮𝐜𝐞𝐝 𝐓𝐡𝐫𝐨𝐦𝐛𝐨𝐜𝐲𝐭𝐨𝐩𝐞𝐧𝐢𝐚**

If you wanna revise, read this thread 👇🏻

#MedTwitter

1/18 Let's get this right, you'll get a lot of consults for suspected HIT. Most of them won't turn out to be HIT but you must know what to do in case it is HIT !

Is every TCP in a patient receiving heparin, HIT?
NOOOO, obviously NOT

The incidence is <1% of all pts on heparin😮

2/18

You know you are a #hematologist when you see more fungal pneumonia than bacterial pneumonia😭

🔸Why are they so common?
IMMUNOSUPRESSION !

🔸The most common cause?
ASPERGILLUS FUMIGATUS

🔸Treatment of choice?
VORICONAZOLE

Let's run through some common radiological findings👇🏻 Image 👇🏻 shows a "HALO SIGN"

The central "nodule" contains the fungal hyphae, the "halo" around represents hemorrhage caused by the angio-invasiveness of the fungus.

This is an EARLY FINDING !!

It is NOT SPECIFIC for IPA, can be seen in GPA etc.

#MedTwitter

You are a young #medicine resident, again 🤣

You are called in for a consult by your OBGYN colleagues, this happens a lot🤣

THROMBOCYTOPENIA (TCP) yet again !

But now we know the basics, rule out pseudoTCP etc. So that's done!

The patient is really thrombocytopenic

What now? 1st Q: What TRIMESTER ??

Trust me, it's important for you to know this.

Let's say the patient is 34 wks; has a manual count of 120k.

We are not worried, this could be gestational TCP but it's a DX of exclusion = r/o alternate causes

Also, TCP never <50k here !

2/15

You are a young #medicine resident, you recieve a call from your surgery colleague 📞

The patient posted for surgery has THROMBOCYTOPENIA (TCP) 😲😭

Here's what you need to know 👇🏼

#MedTwitter

1/12 Does the patient REALLY have TCP ?

TCP is defined as platelet count <150k !!

So, 149k is TCP right ?

Yes, but get a smear to look for platelet clumps, satellitism, large platelets etc.
The smear tells you a lot 💪🏼

2/12

Hey #hematology aspirants, let's talk about #CMV today !! Post allogenic transplant CMV prophylaxis and pre-emptive therapy to be precise.

A short thread 🧵

1/n

#MedTwitter #MedEd #hematology CMV a DNA virus, one of the commonest causes of infections post HSCT

Has the largest genome of any known human virus [200 genes]

Most humans harbour latent CMV, infection aquired in childhood.

Site of latency in humans-❓
In murine models- hepatic sinusoidal cells.

2/n

Want to know why #Mucormycosis is more common post #COVID19 and not so common after leukemia's or other illnesses treated with steroids ?

Read on !! These are the major reasons in my opinion:

1. The NUMBER of #COVID19 pts is far GREATER than the number of leukemia pts we treat in a year. Thus a lot more people are getting steroids at this point in time and thus a lot more are at risk of steroid related complications.

So there are a lot of people asking about the risk factors for #mucor post #covid.

The biggest risk factor isn't the steroid itself, it's the hyperglycemia that it causes. If the sugars are well controlled using insulin the risk is almost negligible. So STOP freaking out !! The 2nd major risk factor is prolonged NEUTROPENIA but that's a problem in our #Hematology patient population and not in #covid patients, so we can safely ignore that for now.