Leukemia Cutis

Today at morning report we discussed rash and acute leukemia.

Rash (or other dermatologic complaints) are often difficult for internists to deal with, as we often lack a lot of experience with them. However, going back to basics, a few key points to make are:

(1) A description of the rash is important. This includes the features of the lesions (i.e. macules, papules, plaques, nodules, bullae, etc), a description of the distribution (localized vs. diffuse, major regions of the body affected, areas spared) and the progression of the lesions over time. It is also important to describe the associated symptoms - fever, pruritis, pain, parasthesia or anasthesia, etc.

(2) Rule out acutely dangerous things. A few key rashes internists should know about are:

• Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
• Pemphigus
• Infections of skin/soft tissue (in particular, necrotizing fasciitis)
• Purpura fulminans (meningococcemia)
• Staphylococcal toxic shock
• Viral exanthems (Note that varicella, measles, etc can be severe and even fatal in adults, especially the elderly)

(3) If in doubt, stop all possible offending drugs and get an urgent dermatology opinion and biopsy.

We talked in more detail about leukemia cutis, a disease caused by infiltration of the skin with leukemic cells. The Canadian Medical Association Journal recently published a short case report with images (although in a child) on this syndrome. Leukemia cutis may portend a worse prognosis in adults with AML.

Management of Ascites

Today at morning report, we discussed the management of ascites.

I wanted to share with you some guidelines and literature:



Chronic Outpatient Management of Ascites

1. Sodium restriction (88 mmol/day [2000 mg/day])


2. Diuretics (oral spironolactone with or without oral furosemide).


3. Fluid restriction only if serum sodium is less than 120 to 125 mmol/L.

Chronic Outpatient Management of REFRACTORY Ascites

1. Serial therapeutic paracenteses.


2. Postparacentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L.


3. For large-volume paracenteses, an albumin infusion of 6 to 8 g/L of fluid removed can be considered.


4. Transjugular intrahepatic portasystemic stent-shunt (TIPS) may be considered in appropriately selected patients who meet criteria similar to those of published randomized trials.

Who Needs SBP Prophylaxis?

1. Anyone who has had SBP before.


2. Anyone with cirrhosis admitted with a variceal bleed. See the NEJM paper


3. Anyone with cirrhosis, ascites ascitic protein less than 1.5, creatinine greater than 106 mmol/L OR BUN greater than 8.9 mmol/L), serum Na less than 130, MELD greater than 9 points with bilirubin greater than 3 mg/dL.

One question that came up was whether prophylaxis should be daily or intermittently. Both regiments have been shown to be of benefit in clinical trials, but there is concern that intermittent dosing will lead to bacterial resistance and therefore the preferred regimen according to the AASLD is daily.

Renal Failure in Ascites

Erik mentioned using albumin in patients with SBP. The major evidence supporting this practice is from an article published in the NEJM in 1999 which randomized patients with SBP to either antibiotics alone or antibiotics with albumin. The investigators found a statistically significant reduction in renal dsyfunction and mortality with this regimen.

There was aslo a recent review article on renal failure and cirrhosis in the NEJM.

See the AASLD Guidelines for more information on the management of ascites.