- Email: [email protected]
Oncologic emergencies
ABSTRACTS Peter Rosen, MD --- editor Director of the Division of Emergency Medicine, Denver'General Hospital
Frank J. Baker, II, MD - - assistant editor Associate Professor and Director, Department of Emergency Medicine, University of Chicago Hospitals and Clinics Oncologic emergencies. Nissenblatt M J, Am Fam Phys 20:104-114, (Aug) 1979. Th e more common oncalogic emergenciesencountered are spinal cord compression, hypercalcemia, superior vena cava syndrome, and pancytopenia. Spinal cord compression, featured by pain and motor and sensory symptoms progressing to autonomic and sphincter dysfunction, develops in 1% to 10% of cancer patients and is easily mimicked. Causes include direct extension and epidural metastases (70% in the thoracic region) and presentation is defined by specific tumor biology. Diagnosis necessitates radiography followed by myelogram and CSF analysis. Treatment is controversial, yet standard m e a s u r e s include h i g h dose steroids, r a d i a t i o n , chemot h e r a p y , and possibly surgical removal or laminectomy. Hypercalcemia may be induced by bony metastases or horm o n e production. S y m p t o m s are those of h y p e r c a l c e m i a from any cause. T r e a t m e n t includes diuresis, oral phosphates, steroids, occasionally Mithramycin and Calcitonin, while simultaneously t r e a t i n g the underlying tumor. Superior vena cava syndrome is caused by malignancy in 95% of cases and diagnosis is usually easy once pericardial tamponade and congestive h e a r t failure are ruled out. Chest films are rarely normal, demonstrating mediastinal m a s s . Radiation therapy can rapidly reverse the symptoms. Steroids a r e n e e d e d only when there is respiratory compromise. Survival is dependent on the underlying tumor histology, with 10% of patients Mive after two years. Pancytopenia results from underlying disease Or its treatment. Even with hematocrits below 30, transfusions are required only if the patient is symptomatic and red cell recovery is not expected. Thrombocytopenia usually doesn't cause bleeding without other coagulation defects, but active bleeding is treated with platelet infusions. Serious infections occur with WBC counts below 1,000. Fluctuance and induration are rare, and tenderness with a fever or fever alone usually indicates infection for w h i c h a n t i b i o t i c s s h o u l d be s t a r t e d i m m e d i a t e l y . Granulocyte infusions are rarely indicated. (Editor's note: Many complications of tumors are rarely seen in the ED because of oncologists' diligence in following their patients. It must be remembered that the chemotherapeutic agents inhibit normal responses, especially to infection, and these patients must be presumed to be sicker than they look.)
Nancy Bodelson, MD emergencies, oncologic Anaerobic bacterial meningitis. Heerema MS, Ein ME, Musher DM, et al, Am J Med 67:219-227, (Aug) 1979. Meningitis caused by obligate anaerobes is" an infrequently recognized disease, and may occur as a complication of a brain abscess which ruptures into a ventricle or the surface of the brain. More frequently it occurs as a result of infection which extends into the central nervous system from an adjacent infected area. Anaerobic meningitis occurred in four patients in whom anaerobic bacteria had not been suspected. The predisposing conditions-included chronic otitis media
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Ann
with mastoiditis, chronic sinusitis, recent craniotomy, and abdominal trauma. Two of the patients were immunosuppressed. Anaerobic bacterial meningitis probably occurs more often t h a n is now recognized. In a patient with a predisposing condition, s u c h a s immunosuppression, head and neck surgery, trauma, or infection, the cerebrospinal fluid obtained for analysis should be transported and cultured anaerobically w h e n meningitis is present or suspected. (Editor's note: One wonders how many aseptic meningitides would actually grow out anaerobes i f appropriately cultured. As elsewhere in the body, there may be cases in which the aerobes are the predominant organism but anaerobes are contributing to the failure
to respond to therapy.)
Frederick K. Seydel, MD
brain, meningitis, bacterial; meningitis, bacterial, anaerobic Penetrating trauma of the lung. Graham JM, Mattox KL, Beall AC Jr, J Trauma 19:665-669, (Sep) 1979. The authors undertook a retrospective study of 373 patients w i t h p e n e t r a t i n g wounds of t h e lung d u r i n g a one-year period. Intercostal tube thoracotomy was the only therapy required in 282 (76%). Thoracotomy was required in 91 patients, usually for repair of associated thoracic injuries rather t h a n complications of lung penetration. Fourteen patients ini t i a l l y t r e a t e d w i t h i n t e r c o s t a l tube d r a i n a g e r e q u i r e d thoracostomy for complications of clotted hemothorax (3%) and empyema (2%)~ The authors recommend intravenous antibiotics (cephalosporins) and 15 cm to 25 cm underwater seal s u c t i o n for all chest tubes. They also r e c o m m e n d early thoracotomy for clotted hemothorax or empyema. (Editor's n o t e : There is, in fact, little evidence for the prophylactic use of antibiotics in simple penetrating chest injury. Retrospective studies cannot answer questions such as this. The incidence of empyema is very low and probably relates as much to satisfactory drainage of the chest as to prophylactic antibiotics.)
Hal Thomas, MD lung, trauma, penetrating; trauma, lung Fournier's syndrome: NecroUzing subcutaneous infection of the male genitalia, Jones RB, Hirschmann JV, Brown GS, et al, J Urol 122:279-281, (Sep) 1979, This syndrome, first described in 1883, was thought to be idiopathic. In this article, the authors describe three broad categories of etiology: local trauma, urinary tract infection, and perianal infection. Upon reviewing 119 reported c a s e s since 1945, they found the average age to be 51.3 years. Diabetes was an important predisposing factor. Clinically, there is rapidly spreading redness and swelling of the scrotum and/or penis accompanied by signs of systemic toxicity. If untreated, the fasciitis develops into gangrene. The microbial flora are similar to normal fecal flora - - a combination of anaerobes and aerobes which may act synergistically to produce t h i s c o n d i t i o n . Most c o m m o n l y , Bacteroides and Fusobacterium or Peptostreptococcus are isolated. Treatment consists of g e n t a m i c i n IM and clindamycin or chloram-
Emerg Med
9:7 (July) 1980
Frank J. Baker, II, MD - - assistant editor Associate Professor and Director, Department of Emergency Medicine, University of Chicago Hospitals and Clinics Oncologic emergencies. Nissenblatt M J, Am Fam Phys 20:104-114, (Aug) 1979. Th e more common oncalogic emergenciesencountered are spinal cord compression, hypercalcemia, superior vena cava syndrome, and pancytopenia. Spinal cord compression, featured by pain and motor and sensory symptoms progressing to autonomic and sphincter dysfunction, develops in 1% to 10% of cancer patients and is easily mimicked. Causes include direct extension and epidural metastases (70% in the thoracic region) and presentation is defined by specific tumor biology. Diagnosis necessitates radiography followed by myelogram and CSF analysis. Treatment is controversial, yet standard m e a s u r e s include h i g h dose steroids, r a d i a t i o n , chemot h e r a p y , and possibly surgical removal or laminectomy. Hypercalcemia may be induced by bony metastases or horm o n e production. S y m p t o m s are those of h y p e r c a l c e m i a from any cause. T r e a t m e n t includes diuresis, oral phosphates, steroids, occasionally Mithramycin and Calcitonin, while simultaneously t r e a t i n g the underlying tumor. Superior vena cava syndrome is caused by malignancy in 95% of cases and diagnosis is usually easy once pericardial tamponade and congestive h e a r t failure are ruled out. Chest films are rarely normal, demonstrating mediastinal m a s s . Radiation therapy can rapidly reverse the symptoms. Steroids a r e n e e d e d only when there is respiratory compromise. Survival is dependent on the underlying tumor histology, with 10% of patients Mive after two years. Pancytopenia results from underlying disease Or its treatment. Even with hematocrits below 30, transfusions are required only if the patient is symptomatic and red cell recovery is not expected. Thrombocytopenia usually doesn't cause bleeding without other coagulation defects, but active bleeding is treated with platelet infusions. Serious infections occur with WBC counts below 1,000. Fluctuance and induration are rare, and tenderness with a fever or fever alone usually indicates infection for w h i c h a n t i b i o t i c s s h o u l d be s t a r t e d i m m e d i a t e l y . Granulocyte infusions are rarely indicated. (Editor's note: Many complications of tumors are rarely seen in the ED because of oncologists' diligence in following their patients. It must be remembered that the chemotherapeutic agents inhibit normal responses, especially to infection, and these patients must be presumed to be sicker than they look.)
Nancy Bodelson, MD emergencies, oncologic Anaerobic bacterial meningitis. Heerema MS, Ein ME, Musher DM, et al, Am J Med 67:219-227, (Aug) 1979. Meningitis caused by obligate anaerobes is" an infrequently recognized disease, and may occur as a complication of a brain abscess which ruptures into a ventricle or the surface of the brain. More frequently it occurs as a result of infection which extends into the central nervous system from an adjacent infected area. Anaerobic meningitis occurred in four patients in whom anaerobic bacteria had not been suspected. The predisposing conditions-included chronic otitis media
72/390
Ann
with mastoiditis, chronic sinusitis, recent craniotomy, and abdominal trauma. Two of the patients were immunosuppressed. Anaerobic bacterial meningitis probably occurs more often t h a n is now recognized. In a patient with a predisposing condition, s u c h a s immunosuppression, head and neck surgery, trauma, or infection, the cerebrospinal fluid obtained for analysis should be transported and cultured anaerobically w h e n meningitis is present or suspected. (Editor's note: One wonders how many aseptic meningitides would actually grow out anaerobes i f appropriately cultured. As elsewhere in the body, there may be cases in which the aerobes are the predominant organism but anaerobes are contributing to the failure
to respond to therapy.)
Frederick K. Seydel, MD
brain, meningitis, bacterial; meningitis, bacterial, anaerobic Penetrating trauma of the lung. Graham JM, Mattox KL, Beall AC Jr, J Trauma 19:665-669, (Sep) 1979. The authors undertook a retrospective study of 373 patients w i t h p e n e t r a t i n g wounds of t h e lung d u r i n g a one-year period. Intercostal tube thoracotomy was the only therapy required in 282 (76%). Thoracotomy was required in 91 patients, usually for repair of associated thoracic injuries rather t h a n complications of lung penetration. Fourteen patients ini t i a l l y t r e a t e d w i t h i n t e r c o s t a l tube d r a i n a g e r e q u i r e d thoracostomy for complications of clotted hemothorax (3%) and empyema (2%)~ The authors recommend intravenous antibiotics (cephalosporins) and 15 cm to 25 cm underwater seal s u c t i o n for all chest tubes. They also r e c o m m e n d early thoracotomy for clotted hemothorax or empyema. (Editor's n o t e : There is, in fact, little evidence for the prophylactic use of antibiotics in simple penetrating chest injury. Retrospective studies cannot answer questions such as this. The incidence of empyema is very low and probably relates as much to satisfactory drainage of the chest as to prophylactic antibiotics.)
Hal Thomas, MD lung, trauma, penetrating; trauma, lung Fournier's syndrome: NecroUzing subcutaneous infection of the male genitalia, Jones RB, Hirschmann JV, Brown GS, et al, J Urol 122:279-281, (Sep) 1979, This syndrome, first described in 1883, was thought to be idiopathic. In this article, the authors describe three broad categories of etiology: local trauma, urinary tract infection, and perianal infection. Upon reviewing 119 reported c a s e s since 1945, they found the average age to be 51.3 years. Diabetes was an important predisposing factor. Clinically, there is rapidly spreading redness and swelling of the scrotum and/or penis accompanied by signs of systemic toxicity. If untreated, the fasciitis develops into gangrene. The microbial flora are similar to normal fecal flora - - a combination of anaerobes and aerobes which may act synergistically to produce t h i s c o n d i t i o n . Most c o m m o n l y , Bacteroides and Fusobacterium or Peptostreptococcus are isolated. Treatment consists of g e n t a m i c i n IM and clindamycin or chloram-
Emerg Med
9:7 (July) 1980