Hemorrhagic Manifestations

[MHKMD]

Wanted to discuss this question:

A febrile 65-year-old man with prostatic hyperplasia and urinary retention develops endotoxic shock. Within 24 hours, he has oozing of blood from all needle puncture sites, extensive ecchymoses and petechiae, and gastrointestinal bleeding. Laboratory studies show hemoglobin concentration of 9 g/dL, platelet count 75,000/mm3, prothrombin time (PT) 20 sec, partial thromboplastin time, activated (aPTT) 50 sec, d-dimer positive. What is an unrelated disease that can produce a similar clinical picture of generalized petechiae and bleeding and similar lab investigation results?

a) Acute lymphoblastic leukemia (ALL)
b) Acute myeloid leukemia (M3)
c) Adenocarcinoma of pancreas
d) Sézary syndrome
e) Thrombotic thrombocytopenia purpura

What do you guys think? For me there were two very good options.

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[sahell]

DIC - M3 is classic. Although ALL may also have DIC, the age doesn't fit. DIC could also be present in pancreatic Ca. TTP is ruled out by labs. Not sure about Sezary. This is one of those where I want to slap the question writer and whoever thought up the concept of single best answer.

 

[MHKMD]

Yes- I was really annoyed by this question because a DIC-like clinical picture can be seen in a few of the answers, although I did bring it down to two of the best possibilities. I found this question to help me cement some knowledge in the presentation of DIC, which is caused by many different clinical scenarios.

I will wait a little longer to post the answer/explanation to see if any one else want to try it.

 

[MHKMD]

So the answer is Acute myeloid leukemia (M3), although I do not necessarily think that the explanation for why Pancreatic Adenocarcinoma is incorrect.

 

[MHKMD]

Option A (Acute lymphoblastic leukemia (ALL)) is incorrect. In ALL, the clinical features include lymphadenopathy and splenomegaly. DIC is not a feature of ALL.

Option C (Adenocarcinoma of pancreas) is incorrect. Adenocarcinoma of the pancreas could be associated with Trousseau syndrome, which includes migratory thrombophlebitis caused by thrombogenic substances released by the cancer cells. It involves veins and is patchy and migratory. The clinical picture is not like DIC.

Option D (Sézary syndrome) is incorrect. This is a form of cutaneous T-cell lymphoma characterized by generalized exfoliative erythroderma and leukemic cells with cerebriform nuclei. DIC is not a clinical feature.

Option E (Thrombotic thrombocytopenic purpura) is incorrect. DIC is associated with fibrin clots, multiple coagulation factor deficiencies, activation of the fibrinolytic system, and thrombocytopenia. Therefore, conditions that produce thrombocytopenia, such as autoimmune thrombocytopenia and thrombotic thrombocytopenic purpura, do not explain all of the clinical and laboratory findings that are present in this patient.

 

[MHKMD]

I though this question helped me realize an important point or distinction between Acute Promyelocytic Leukemia and Pancreatic Adenocarcinoma that I previously missed: the clinical presentation (and lab values) differ between chronic DIC, commonly seen in adenocarcinoma and acute DIC, common in APL. In chronic DIC, the clinical picture is that of an insidious onset, where normalization (or elevation) of PT and PTT is commonly seen and bleeding is discrete, low-grade, and restricted to skin/mucosa. Thrombotic manifestation in the venous system is dominant in chronic DIC. This is in comparison of acute DIC, where onset is fulminant and severe bleeding dominates the clinical picture. As seen in question, acute DIC can present with hemodynamic instability and shock.

Maen Karadsheh

 

[sahell]

The answer explanations are very cursory. I had a question on Rx - classic DIC presentation with LN and splenomegaly - it was ALL because of age. Solid tutors most definitely cause DIC so that's obviously wrong.

It's enlightening to learn that there's a chronic DIC but imo this is a poorly thought out question where they want you to think of the obvious answer. I feel sometimes (not always) question writers don't expect you know a lot. The average student knows DIC = AML and that's probably what they wanted to test.

Thanks for sharing