CP 5, 6, 14, 35

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Author:
Anonymous
ID:
41619
Filename:
CP 5, 6, 14, 35
Updated:
2010-10-12 08:23:25
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Bone pain Bone tumours
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Description:
osteoporosis, osteosarcoma, multiple myeloma
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  1. Name 7 diseases likely to predispose to a fracture of the neck of the femur in a woman of 70yo?
    • Osteoporosis
    • Osteomalacia
    • Paget's disease of bone
    • Malignancies - osteosarcoma, B-cell lymphoma, multiple myeloma
    • Renal osteodystrophy
    • Hyperparathyroidism
    • Stroke /TIA
  2. In an 70yo women with pathological fracture, name 6 Ix.
    • FBC - haematological malignancies
    • Bone scans
    • Bone biopsy
    • Bone density e.g. dexa, U/S, quantitative CT
    • Biochemistry - Ca, phosphate, Vit D, PTH
    • Bone resorption markers - urinary hydroxyproline (for Paget's), urinary pyridine x-links of collagen
  3. Name 7 groups of age-independent risks for osteoporosis.
    • FHx
    • Glucocorticoids use
    • Low BMI
    • Medical disorders e.g. IBD, hyperparathyrodism, RA
    • Premature menopause / hypogonadism
    • Prolonged immobility
    • SNAP
  4. Describe 5 treatments for menopause.
    • Anti-resorptives
    • Bisphosphonates - mainstay of Tx
    • SERM e.g. raloxifene
    • HRT - not recommended in >51yo, used for premature menopause
    • Calcitonin - if other Tx are exhausted
    • New bone formation
    • PTH (Forteo) - increases bone turnover but also bone formation
  5. Name 3 histological finding of osteoporosis.
    • Widely spaced and thinner trabeculae
    • Haversian canals widening
    • Mineral content of remaining bone normal
  6. Name 4 groups of DDx (2 examples each) for 3/52 of leg pain & swelling in a 13yo.
    • Trauma - soft tissue, fracture
    • Infection - osteomyelitis, septic arthritis
    • Inflammation - juvenile RA, seronegative arthropathy
    • Tumour - osteosarcoma, Ewing's sarcoma, osteochondroma, aneurysmal bone cyst, osteoma
  7. Name 5 Ix to perform on a boy with suspected osteosarcoma. What is the Ix for Dx?
    • FBC - LFT, U/E, CRP, WCC, LDH
    • X-ray - lytic + blastic, sunray appearance, Codman's triangle
    • Joint aspiration
    • Bone scan & Gallium scan
    • MRI & CT

    To Dx - bone biopsy
  8. What is known about the pathogenesis of osteosarcoma?
    • Develop at sites of greatest bone turnover e.g. Paget's
    • Hereditary - mutation in Rb
    • Non-hereditary - TP53 gene (tumour suppressor) is mutated and MDM2 (binds to TP53) is over expressed
  9. A 65yo M came with corticospinal dysfunction, name 6 DDx.
    • Spinal cord compression due to malignancy - prostate, lung, myeloma, NHL, ependyoma
    • Fracture
    • Disc prolapse
    • Infection e.g. TB, epidural abscess
    • Haematoma (warfarin)
    • Stroke/TIA - unlikely if bilateral symptoms
  10. Interpret: Nucleated RBC ++, metamyelocytes ++, Rouleux ++
    • Leukoerythroblastic picture - immature RBC and WCC
    • DDx - marrow infiltration or blood loss
    • Rouleaux - RBC that form when there's high plasma protein concentration (raised ESR)
    • DDx - inflammation, cancer, infections
  11. What tests to order if marrow infiltration is suspected? (name 4)
    • Skeletal survey e.g. MRI
    • Urine and serum electrophoresis and immunofixation
    • Bone marrow biopsy
    • Bloods - FBC, film, ESR, UEC, LFT
  12. What are Bence Jones proteins?
    • These are monoclonal immunoglobulin light chains in the serum/urine
    • Produced by neoplastic plasma cells, present in 2/3 of MM
    • BJ + hypercalcemia can impair renal function enabling the protein to enter the urine.
  13. Name 4 key signs of multiple myeloma.
    • CRAB:
    • Calcium elevation
    • Renal insufficiency
    • Anaemia
    • Bone lesions (lytic)
  14. Describe the pathogenesis of multiple myleoma.
    • IL-6 may play a role in driving myeloma cell proliferation
    • Osteoclast activating factors (OAF) is made by the myeloma cells [OAF activity is mediated by several cytokines e.g. IL-1, VEGF, TNF].
  15. What leads to renal insufficiency in patients with multiple myeloma? (Name 6 ways)
    • Hypercalcemia
    • Bence Jones proteins damages tubules and interstitium
    • Glomerular deposits of amyloid
    • Recurrent infections
    • NSAIDS use
    • Hyperuricemia
  16. What is MGUS?
    • = Monoclonal gammopathy of undetermined significance
    • A paraprotein is present in the blood (monoclonal band on electrophoresis) but
    • with no other features of myeloma
    • Occurs in 1% of 50yo +
  17. What differentiates benign paraproteinaemia from a malignant one? (4 features)
    • No bone marrow infiltration
    • Low/constant paraprotein levels
    • Absence of urine light chains
    • Normal levels of other serum immunoglobulins

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