Physicians Awareness To Haematology (PATH) Newsletter
Dear friends, colleagues and seniors,
As I write this newsletter, greenery would be everywhere and I hope most of you would be outdoors on weekend enjoying Nature! I once again take this opportunity to thank you all for the support to Jeevan Amrut Haematology Center since last 3 years. I am glad to tell you all that we have successfully completed 40 bone marrow transplants to date in Aurangabad, Maharashtra. I hope you keep your faith in our institute and help us serve better. Sometimes I am not able to talk to you on phone and this sometimes can cause some misconceptions and I sincerely apologize for the same.
Today we will be discussing two classical cases and I hope you enjoy it.
Case 1: A Fifty one year old female had history of lower back pain for 6 months before coming to me. She was seen by her family physician and given NSAIDs with relief for few days. She developed fever and lower respiratory tract infection and was admitted to a physician for 5 days. Hb was 8.0 wbc: 17,200 and platelets were 4.1 lakhs. A chest X ray done then showed ?lytic lesions. Pneumonia was treated and she was discharged. Back pain continued. She then went to an orthopaedic surgeon for evaluation and on MRI was found to have osteoporosis with ? infiltrative disease and hence was immediately referred to hematology for further evaluation.
Her main complaint was the pain and weakness and recently developed urinary tract infection. Her Hb was 7.1, wbc: 12,100 and platelets were 3.0 lakhs. She could not walk and was very weak. She had developed compression fracture of D12 vertebra. Bone marrow was done in view of infiltrative disease and Multiple Myeloma was diagnosed as plasma cells in her bone marrow were 58% (normal < 2%). Her Creatinine was 3.1. Serum calcium was normal. Further molecular studies confirmed myeloma with “M” band on serum immunofixation studies.
Treatment was started with Inj. Bortezomib, Dexamethasone and lenolidomide (Standard triple drug therapy). Her clinical condition improved and without transfusion her Hb improved to 9.2 in 1 month and creatinine setteled down to 1.2. Her back pain persists but now she can walk with an abdominal belt.
She will need chemotherapy for total 4-6 months and then she will be taken up for autologous bone marrow transplant.
About Multiple Myeloma:
It is a type of cancer which affects bone marrow (hence we may get anemia, leucopenia or thrombocytopenia), kidneys and the skeletal system (leading to lytic bone lesions). It causes reduced immunity leading to recurrent infections. Many patients just present with back pain!
a) Anemia may have Causes other than nutritional deficiencies.
b) Anemia in elderly population can have malignancy as an underlying cause.
c) Unusual infection should make us think about low immunity.
d) NSAID medication should not be given for a long time
e) X-ray should be reported by qualified radiologist if possible. f) Timely referral is important in diseases like malignancy
A forty two year old male reported to his treating physician with pain in his right leg. He had no particular swelling, no sign of obvious inflammation. He was given pain killers and asks to see the physician in 5 days. Patient went back to his physician a month later with increasing pain and swelling and was then diagnosed with Deep vein thrombosis. The clot extended from femoral vein to external iliac vein. There was no clot in Inferior vena cava. In view of the major thrombosis he was referred to a cardiologist.
He was seen and asked to get admitted with an explanation that he would need thrombolysis and placement of IVC filter (this is like a small umbrella made out of special material which is placed in the inferior vena cava so that the clot from lower limb does not reach the pulmonary vasculature hence preventing pulmonary embolism) with a budget of more of than 1.0 lakh.
Patient was referred by his local family doctor to me for a second opinion. He had pain and swelling. No breathlessness. In his colour Doppler report the clot was of subacute nature.
What advice do I give this gentle man?
A] What his is ideal management?
B] Does he need thrombolysis?
C] Does he need IVC filter?
D] How many days admission is required if at all?
E] Does he need an antiplatelet drug also?
F] Does he routinely need statins?
I started him on low molecular weight heparin and oral anticoagulation with warfarin. He was not ready for admission (ideally in a large DVT one needs admission for at least 3-4 days to monitor for pulmonary embolism). I advised him that he does not need thrombolysis and he also does not need IVC filter.
Indications of IVC filter in DVT?
A] Acute DVT where anticoagulation therapy is contraindicated (e.g immediately post major surgery,
Cancer where platelets are low, DVT in a patient who has active bleeding and henceanticoagulation is contraindicated etc.)
B] Recurrent DVT in spite of adequate anticoagulation.
C] Extensive DVT with impending embolism i. e clot extending in IVC.
Just an extensive DVT alone does not merit an IVC filter insertion.
What are the problems with IVC filter?
A] Everyone is excited to insert a filter but we forget to remove it?? A persistent filter can be a site of a new clot and then the patient can get bilateral DVT?
B] Most of the cases IVC filter insertion is a temporary measure.
C] Cost involved is huge and patient and family can be worried unnecessarily.
I have come across many cases of acute DVT where thrombolysis was carried out. In my opinion we think “any clot should be thrombolysed”, but we should remember that DVT is a venous clot unlike coronary syndrome or stroke where it is an arterial clot.
It is indicated only in extensive acute DVT where it is “limb threatening” or a case of PE where hypotension is present.
Jeevan Amrut Hospital news:
We have stared state of the art 3 bedded ICU with good neutropenic care. Dr. Sudhakar Hase, MD Pulmonary Medicine and IDCCM, is the incharge and intensivist for the same.
With the trust shown by all of you, team Jeevan Amrut crossed the landmark of serving and taking care of 5,000 patients i.e. Families.
Jeevan Amrut Newsletter –
This is something new we have started with the intention to meet you at regular intervals on this virtual platform to discuss interesting hematology cases, clinical and laboratory updates and various news related to hematology through this newsletter. Its my humble request to share your thoughts regarding this initiative.
Seeking your blessings.
Dr Manoj Toshniwal – Contact No – 9225300842