Archer 106.... - forever07

[ArchivalUser]

D. riba causes hemolytic anemia. if transfusion was an option i'd have choosed that one first.
A. CAP. honestly I'll treat him outpt since no comorbidities described, no high fever, no toxic and if he failed, then hospi.

[ArchivalUser]

yuyhope:

ADVERSE EFFECTS OF RIBAVIRIN —

Ribavirin is generally well tolerated. The major adverse effects include hemolysis, and nonspecific fatigue, depression, insomnia, vertigo, anorexia, nausea, nasal congestion, and pruritus . Anemia (defined as a hemoglobin below 10 g/dL) requiring dose reduction occurs in 10 to 15 percent or patients; the hemolysis is reversible after discontinuing the drug. Use of erythropoietic growth factors can help support the hemoglobin concentration and thereby permit continued use of higher doses of ribavirin

**Hemolysis typically becomes an issue** only in patients who have preexisting anemia, renal insufficiency, or coronary artery disease . In addition, chronic hemolysis induced by prolonged therapy with ribavirin can lead to increased deposition of iron in the liver. In one report, for example, the average rate of hepatic iron accumulation in six patients who had received ribavirin for 6 to 12 months was 1500 mcg/year . The authors predicted that hepatic iron concentrations might enter the range clearly associated with hepatic fibrosis after approximately 15 years of continuous therapy. Other possible long term complications of hemolysis, including the development of gallstones, were not addressed.

As a result of hemolysis, ribavirin treatment may be associated with a mild reversible increase in serum bilirubin and uric acid. ***Neither condition requires modification of treatment.***

[ArchivalUser]

pt labs were normal 4 weeks ago and he just has "mild" SPM, i'd expect hypersplenism with much bigger SPM. I feel like that's a dis tractor.
2nd question a bit confusing too. A or B ?. usually levo is 2nd ligne b/c concern about increasing resistance. I don't know if the fact that he did not have his pneumo vacc should incite us to use levo as first ligne. for now i'll go with A.

[ArchivalUser]

"The primary observed serious adverse side effect of ribavirin is hemolytic anemia, which may worsen preexisting cardiac disease. The mechanism for this effect is due to ribavarin's buildup inside erythrocytes. Oxidative damage to erythrocyte cell membrane is usually inhibited by glutathione; however, with reduced ATP levels caused by ribavirin, glutathione levels are impaired, permitting oxidative erythrocyte cell lysis. The gradual loss of erythrocytes leads to anemia"

This patient has pancytopenia- while ribavirin only causes hemolysis of RBC's and anemia..
His platelets are 600000 and WBC's are 3000..

Hence, I still feel it points towards hypersplenism.

[ArchivalUser]

platelets are 60000, typo!

[ArchivalUser]

For. 106, this is severe form of side effects not only due to ribavirin induced haemolysis, but also combination effects of interferon and ribavirin.

So I choose to stop ribavirin that will relief sym. I still think for D.

For 105, case is typical lobar pneumonia, most common is st pneumo, so I will choose levoflox.

Any suggestion?

[ArchivalUser]

http://www.usmleforum.com/showthread.php?tid=548672

[ArchivalUser]

Thanks jatin

[ArchivalUser]

106. Increased LDH, increased unconjugated bili, low hapto show that it is ribavirin induced acute hemolytic anemia. Stop ribavirin is the first answerr

105. By CURB65 score, the patient needs admission because age > 65

[ArchivalUser]

Thanks for confirmation, glad to hear from you.