Pearls from Dr. David Diuguid

New diagnosis of multiple myeloma in a man with back pain and renal failure


  • >50% of patients with new symptomatic MM have bone pain due to lytic lesions

    Posted 05/29/16 03:16:50 PM by Matthew Cummings

  • Renal failure is common in MM (CRAB): usually due to cast nephropathy (filtered monoclonal free light chains precipitate and cause obstruction)

    Posted 05/29/16 03:17:11 PM by Matthew Cummings

  • Seeing plasma cells on the manual differential is ALWAYS abnormal and warrants bone marrow biopsy

    Posted 05/29/16 03:17:31 PM by Matthew Cummings

  • Urine dipstick only picks up albumin and does not pick up monoclonal proteins --> despite protein gap in MM we do not see proteinuria (unless concomitant AL-amyloid-related glomerulopathy)

    Posted 05/29/16 03:18:04 PM by Matthew Cummings

  • Beta-2-microglobulin is usually elevated in renal disease, thus it is a less useful and less specific diagnostic marker in MM (but useful in prognosis in combination with albumin and cytogenetics --> international staging system)

    Posted 05/29/16 03:19:46 PM by Matthew Cummings

  • For further reading...

    Review: Kidney disease in multiple myeloma
    Review: Multiple myeloma (NEJM)

    Posted 05/29/16 03:22:49 PM by Matthew Cummings

  • 35 y/o post-partum woman p/w AMS, AKI, anemia, thrombocytopenia, found to have catastrophic APS


  • Diagnosis of anti-phospholipid ab. syndrome (APS)

    Posted 09/08/16 09:04:39 AM by Matthew Cummings

  • Thrombotic microangiopathies -- often difficult to distinguish 

    Posted 09/08/16 09:06:42 AM by Matthew Cummings

  • Catastrophic APS

    Posted 09/08/16 09:07:39 AM by Matthew Cummings

  • Catastrophic APS Diagnosis
    1. Evidence of clinical disorder of 3+ organ systems
    2. Development of manifestations within 1 week
    3. Laboratory confirmation of presence of aPL ab.
    4. Tissue confirmation of small-vessel occlusion in 1+ organ or tissue
    Typically will initiate therapy based on clinical diagnosis (1-3), but often will push for tissue biopsy 

    Posted 09/08/16 09:12:04 AM by Matthew Cummings

  • Principles of APS Management

    Posted 09/08/16 09:13:37 AM by Matthew Cummings

  • For further reading...

    Approach to catastrophic thrombotic syndromes (Blood)
    CAPS: international guidelines for diagnosis and management
    Atypical HUS (NEJM Review)

    Posted 09/08/16 09:41:47 AM by Matthew Cummings

  • 47 y/o woman w/ hx Holt-Oram syndrome, RA, APLS, p/w fatigue, found to have auto-immune hemolytic anemia


  • Macrocytosis does NOT rule out hemolytic anemia (HA) --> retics are larger than mature RBCs and may elevate MCV

    Posted 12/28/16 09:19:54 AM by Matthew Cummings

  • Laboratory signs of hemolytic anemia

    Posted 12/28/16 09:25:25 AM by Matthew Cummings

  • Most urgent consideration when suspecting hemolytic anemia?

    Posted 12/28/16 09:26:48 AM by Matthew Cummings

  • Blood smear findings in auto-immune hemolytic anemia?

    Posted 12/28/16 09:29:58 AM by Matthew Cummings

  • Hemolytic anemia and VTE

    Posted 12/28/16 09:31:53 AM by Matthew Cummings

  • Coombs testing

    Posted 12/28/16 09:36:15 AM by Matthew Cummings

  • Warm auto-immune HA

    Posted 12/28/16 10:27:55 AM by Matthew Cummings

  • Cold agglutinins auto-immune HA

    Posted 12/28/16 10:28:39 AM by Matthew Cummings

  • Treatment of auto-immune HA

    Posted 12/28/16 10:42:31 AM by Matthew Cummings

  • For further reading...

    Hypercoagulability and thrombotic complications in hemolytic anemias
    How I treat autoimmune hemolytic anemias in adults (Blood Review)

    Posted 12/28/16 10:43:38 AM by Matthew Cummings

  • Middle aged man w/ hx DVT/PE, presenting w/ chronic DIC likely 2/2 cutaneous TMA vs. pancreatic IPMN


  • ISTH Criteria for DIC (2001)

    Posted 03/14/17 09:33:44 AM by Matthew Cummings

  • Rationale for of heparin products to treat DIC

    Posted 03/14/17 09:40:00 AM by Matthew Cummings

  • For further reading...

    Bleeding and Coagulopathies in Critical Care (NEJM Review 2014)
    DIC Review (NEJM 1999)

    Posted 03/14/17 10:16:44 AM by Matthew Cummings

  • 23 y/o M no PMH presents with fevers and weight loss


  • Posted 04/18/17 10:17:03 AM by Ying Liu

  • Hemophagocytic Lymphohistiocytosis (HLH)

    Posted 04/18/17 10:17:49 AM by Ying Liu

  • For further reading...

    Posted 04/18/17 10:19:06 AM by Ying Liu

  • 41yo F with rash for 1 day found to have ITP


  • Evaluating thrombocytopenia

    If platelets are severely low, consider quinine-induced thrombocytopenia, ask about tonic water ingestion!

    Managing immune thrombocytopenic purpura (ITP)

    Posted 06/27/17 03:19:29 PM by Iheanacho (Obi) Emeruwa

  • Severe bleeding events in adults and children with primary immune thrombocytopenia: a systematic review
    Initial Treatment of Immune Thrombocytopenic Purpura with High-Dose Dexamethasone
    High-dose dexamethasone vs prednisone for treatment of adult immune thrombocytopenia: a prospective multicenter randomized trial

    Posted 06/27/17 03:24:14 PM by Iheanacho (Obi) Emeruwa

  • 29YOF p/w SOB, epistaxis, menorrhagia found to have pancytopenia--->aplastic anemia


    49YO Jehovah's p/w MAHA, acute renal failure found to have atypical HUS


    73yoF w/ strep Pneumo PNA and catastrophic antiphospholipid syndrome


    83YOF p/w pancytopenia


    70 yo M with DM1 p/w DKA with course c/b anemia 2/2 AIHA


    66 yo F with DM2 and RA who p/w fatigue and dizziness, found to have acquired factor VIII inhibitor


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