A challenge

[Gokhu]

A 72 yp pt has Alk. phos 300 and Calcium 7 mg/dL, LDH 530. Otherwise his labs are normal.
What do you suspect?

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[GooglieGoo]

That you're a second year student who doesn't want to look up the answer to a test question yourself.

 

[vkrn]

Note OP's join date, but appreciate OP's M.I.N.D. effort.

 

[GooglieGoo]

"M.I.N.D. effort"? Google is failing me.

 

[Geri_Gal]

I thought the OP was trying to engage in clinical discussion. Posters in the anesthesiology forums often do this -- it is quite interesting to read. I'll bite...any more history? My brain is on "vacation" mode until June 12th!

...and what is "M.I.N.D." effort?

 

[Adcadet]

A 72 yp pt has Alk. phos 300 and Calcium 7 mg/dL, LDH 530. Otherwise his labs are normal.
What do you suspect?

Some history would be nice! Maybe a gender, too! I'm assuming that this patient is roughly normotensive (helps eliminate weird adrenal problems, including Addison's and pheo), and the Cr and BUN were normal as well. I love checking TSH's, and assume this patient's TSH is normal or he/she is on appropriate replacement.

I don't know what your lab's normals are, but it would seem the alk phos, Ca, and LDH are all up. This suggests a process that is destructive of bone and some cells are dying (LDH is up), and I would love some history - any bone pain? My immediate suspicion would be towards multiple myeloma, especially given the patient's age, and I would get an SPEP/UPEP to look for a monoclonal spike. Paget's might also do this (hmm...will Pagets give you an elevated LDH?) TB could also do some of this (do we exposure history, or maybe a PPD?), as could other malignancies (add in a uric acid as we want to watch for tumor lysis syndrome and it would be nice to have a baseline). If there are any localizing complaints I would go for some plain films. Do we have an ESR or CRP? If it's looking like Pagets or MM I might start thinking about a bone scan.

OK, did this soon-to-be intern miss something major?

 

[vkrn]

MIND is the free software that the OP has offered to folks. I haven't tried it so can't vouch for anything.

 

[stergs]

Ca of 7 is low; depending on the Albumin. Find the proper ranges first.

 

[Adcadet]

Ca of 7 is low; depending on the Albumin. Find the proper ranges first.

Sort of defeats the purpose if I look everything up.

 

[lfcdoc]

Some history would be nice! Maybe a gender, too! I'm assuming that this patient is roughly normotensive (helps eliminate weird adrenal problems, including Addison's and pheo), and the Cr and BUN were normal as well. I love checking TSH's, and assume this patient's TSH is normal or he/she is on appropriate replacement.

I don't know what your lab's normals are, but it would seem the alk phos, Ca, and LDH are all up. This suggests a process that is destructive of bone and some cells are dying (LDH is up), and I would love some history - any bone pain? My immediate suspicion would be towards multiple myeloma, especially given the patient's age, and I would get an SPEP/UPEP to look for a monoclonal spike. Paget's might also do this (hmm...will Pagets give you an elevated LDH?) TB could also do some of this (do we exposure history, or maybe a PPD?), as could other malignancies (add in a uric acid as we want to watch for tumor lysis syndrome and it would be nice to have a baseline). If there are any localizing complaints I would go for some plain films. Do we have an ESR or CRP? If it's looking like Pagets or MM I might start thinking about a bone scan.

OK, did this soon-to-be intern miss something major?

I dont' know if you've missed something as I too am only a soon to be intern. (yikes) For me though, I thought mutiple myeloma only increases your alk phos if you also have a fracture, and also I would expect high Ca instead not low. I don't know if Paget's can give you an inc. LDH, but I think it usually has a normal Ca (isolated increased alk phos is the textbook picture I think, but yes, I know the patient's didn't read the book).

I agree the bone mets/mlgncy is a good thought. I think that a blastic lesion could increase the alk phos (bone turnover) and lower the calcium (b/c it's blastic). So are there any malignancies that would have blastic mets and an increased LDH as a marker? I'm not sure, would have to took it up and I'm too lazy right now.

 

[iatrosB]

I dont' know if you've missed something as I too am only a soon to be intern. (yikes) For me though, I thought mutiple myeloma only increases your alk phos if you also have a fracture, and also I would expect high Ca instead not low. I don't know if Paget's can give you an inc. LDH, but I think it usually has a normal Ca (isolated increased alk phos is the textbook picture I think, but yes, I know the patient's didn't read the book).

I agree the bone mets/mlgncy is a good thought. I think that a blastic lesion could increase the alk phos (bone turnover) and lower the calcium (b/c it's blastic). So are there any malignancies that would have blastic mets and an increased LDH as a marker? I'm not sure, would have to took it up and I'm too lazy right now.

possibly prostate cancer (patient gender?)

I think you're right about the MM not raising Alk phos

 

[Gokhu]

-------------------------------
Snap differential
-------------------------------
1. Hypocalcemia: - MEASURE SERUM MG, , , , , Detected, MIND score: 6
2. Pancreatitis - High LDH, Low serum total calcium, MIND score: 2
3. Sepsis: - High Alk.Phos, Low serum total calcium, MIND score: 2
4. Liver failure: - Hilg Alk.Phos., , MIND score: 2
5. Liver tumor: - High LDH High Alk.Phos. MIND score: 2
6. Epstein Barr virus: - High LDH High Alk.Phos. MIND score: 2
7. Cytomegalovirus: - High LDH High Alk.Phos. MIND score: 2
8. Pulmonary infarction: - High LDH High Alk.Phos. MIND score: 2


9. Myocardial infarction: - High LDH, MIND score: 1
10. Vit D def. - Low serum total calcium, MIND score: 1
11. Pseudohypoparathyroidism - Low serum total calcium, MIND score: 1
12. Hypomagnesemia: - Low serum total calcium, MIND score: 1
13. CNS lesion: - High LDH, MIND score: 1
14. CHF: - High Alk.Phos, MIND score: 1
15. Hyperthyroidism: - High Alk.Phos, MIND score: 1
16. Hyperparathyroidism: - High Alk.Phos, MIND score: 1
17. Kidney Infarction: - High LDH,MIND score: 1
18. Cerebrovascular accident: - High LDH,MIND score: 1
19. Cardiopulmonary disease: - High LDH,MIND score: 1
20. Ischemic hepatitis: - High LDH,MIND score: 1
21. Liver metastasis: - High LDH,MIND score: 1
22. Collagen Vascular Disease: - High LDH,MIND score: 1
23. Megaloblastic anemia: - High LDH,MIND score: 1
24. Intestinal Obstruction: - High LDH,MIND score: 1
25. Muscle trauma: - High LDH,MIND score: 1
26. Hypotension/Shock: - High LDH,MIND score: 1
27. Neoplasm: - High LDH,MIND score: 1
28. Vitamin B12 deficiency: - High LDH,MIND score: 1
29. Folate deficiency: - High LDH,MIND score: 1
30. Fluid sequestration: - Pancreatitis suspected x2, MIND score: 1
31. Hypothyroidism: - High LDH, MIND score: 1
32. Multiple myeloma - High Alk.Phos, MIND score: 1
33. Paget's disease of bone - High Alk.Phos, MIND score: 1
34. Vit. D toxicity - High Alk.Phos, MIND score: 1
35. Acromegaly - High Alk.Phos, MIND score: 1
36. Blood transfusion - High LDH, MIND score: 1
37. SLE: - High LDH, MIND score: 1
38. Hemolysis: - High LDH, MIND score: 1
39. Leukemia. - High Alk.Phos, MIND score: 1
40. Estrogen. - High Alk.Phos, MIND score: 1
41. Ulcerative colitis: - High Alk.Phos. MIND score: 1
42. Bowel Perforation: - High Alk.Phos. MIND score: 1
43. Fatty liver: - High Alk.Phos. MIND score: 1
44. Alcoholic Hepatitis: - High Alk.Phos. MIND score: 1
45. Primary Biliary Cirrhosis: - High Alk.Phos. MIND score: 1
46. Drug-induced liver disease: - High Alk.Phos. MIND score: 1
47. Hepatic granuloma: - High Alk.Phos. MIND score: 1
48. Hepatic cyst: - High Alk.Phos. MIND score: 1
49. Cholecystitis: - High Alk.Phos. MIND score: 1
50. Cholelithiasis: - High Alk.Phos. MIND score: 1
51. Primary Sclerosing Cholangitis: - High Alk.Phos. MIND score: 1
52. Oran contraceptives: - High Alk.Phos. MIND score: 1
53. Albumin injected: - High Alk.Phos. MIND score: 1
54. Myelofibrosis: - High Alk.Phos. MIND score: 1
55. Erythromycin: - High Alk.Phos. MIND score: 1
56. Phenothiazines: - High Alk.Phos. MIND score: 1

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